Common, Not Normal: Pelvic Organ Prolapse & Urinary Incontinence

Dr Gavin Nimon: 0:29

Do you ever leak when you cough, laugh or run? It's a question that almost never gets asked in a consult, and yet close to four in 10 Australian women would answer yes. Many have quietly stopped running, skipped the trampoline with the kids, or mapped every toilet between the home and work, and most have been told or have told themselves that it's simply what happens after babies or after 50. Today we're gonna take that idea apart. Pelvic organ prolapse and urinary incontinence are common, But common isn't the same as normal, and the great majority of women can be helped from the pelvic floor through pessaries and physiotherapy all the way to surgery. G'day and welcome to Aussie Med Ed. The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders, past, present, and emerging, and recognising their ongoing connection to land, waters, and culture. I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you're practising or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live. My guest today is Dr. Fariba Behnia-Willison. an Adelaide gynecologist who specializes in female pelvic medicine and reconstructive surgery and advanced single incision laparoscopy. She completed her medical degree in Germany, trained in obstetrics and gynecology in Sydney, and holds a master's in minimally invasive surgery from the University of Adelaide. Fariba is the founder of FBW Gynecology Plus, a senior consultant at the Flinders Medical Center and a senior lecturer at Flinders University. And her doctoral research focused on new surgical and regenerative approaches to pelvic floor repair. She's also founded Desert Floor, which supports women affected by female genital mutilation, and she'll be back to talk about that in a future episode. As always, this conversation is general medical education rather than individual advice. If anything today sounds familiar, please talk to your GP or pelvic health physiotherapist. welcome Fariba. Thank you very much for coming on Aussie Med Ed. First of all, pelvic organ prolapse and urinary incontinence. What are we really talking about? What is pelvic organ prolapse, and how common is urinary incontinence? Perhaps you can tell me a little bit about it, please.

Dr Fariba Willison-Behnia: 2:57

Thank you, Gavin, for having me. it's my pleasure to join this programme. pelvic organ prolapse and incontinence affect 60% of women over their lifetime It is herniation of, organs or descent of organs into the vagina. It can cause structural damage, or it can cause muscle damage or overactivity of the muscle. So basically, we separate the prolapse and stress incontinence into a structural issues and urge incontinence into, uh, overactive bladder. So it means the, problem is the muscle. When we have a herniation, it means that either the muscle is damaged or the connective tissue in the vagina are damaged. And when we have over, active bladder, it could be also a number of things such as lifestyle, having too much of caffeinated drinks, obesity, smoking, alcohol consumption that cause that problem. So, and, those, issues can be hand-in-hand or they can be isolated. So to dissect, I go through prolapse first. the prolapse the causes can be childbirth, but not childbirth alone. Caesarean section is only twenty percent protective. it can be caused by pregnancy itself. aging, menopause, smoking, chronic cough, constipation, and anything that increases the intra-abdominal pressure. So for example, a lot of women do heavy weights. They might not even have a baby, but, standing up or sitting down and doing the weights causes problem because obviously we have a hole in our pelvic floor that called vagina, and gravity is not our best friend. So we can do a lot of, gym activities, but we just have to modify our, positions a little bit or learn to brace and have a really good core muscle because all the muscles are, together before we lift anything. In terms of, stress incontinence, the bladder neck and the bladder itself both are intra-abdominal organs, and through childbirth or anything that we have mentioned, all the risk factors, the bladder neck can descend into the vagina. Therefore, the pressure that it is on the top of the bladder is not equal to the pressure that is on the bl- bladder neck. and hence, the sphincter is not able to hold the urine. And when the woman coughs, the woman leaks. So it is very important to know that the majority of the stress incontinence happen to women who are only thirty years old And that is those women who wanna jump on the trampoline and play with their children, that they can't, do it, or they are worried to do it, or they are embarrassed to do it. And simple activities such as just putting a tampon in the vagina can assist them to go back into their activities. Losing the weight that they gained during the pregnancy, avoiding constipation, and lifting unnecessary stuff. For example, the bonding with the baby is not in carrying the baby all the time. You can lie on the floor and play with the baby. Or when the child is five years old, you don't need to lift the baby all the time, or the furniture needs to be changed, they can ask the husband to help. So there are little things that they can do, and if they have chronic cough, if they have any, asthma, they can see their GP and make sure that they are good. And also, a lot of women are very adamant to have a vaginal birth. Vaginal birth is good as long as it is straightforward, maybe a bit of vacuum and assisted delivery. If the head is low, it's fine. Sometimes a little episiotomy would assist. But there are women who are hours and hours in, in a labour. They do the vacuum, then they do the forceps, and they still wanna use Killian forceps and different manoeuvres to get going. And that is when the pelvic floor is damaged, especially if, intercultural and interracial, pregnancies happen. A small, uh, petite Asian lady with, um, uh, Anglo-Saxon man, so there is a dis-disproportionate in terms of genetic there, and the baby might be much bigger than for the shape of the pelvis of that woman. So the-- these discussions have to happen with the, obstetrician, closer to the term to see how, likely is a normal vaginal birth, how far they go, and maybe caesarean section at some point would be protective. But I would encourage everyone to continue to have vaginal birth because that is the normal way to do it, and caesarean section is a major surgery and can have its complication.

Dr Gavin Nimon: 8:10

Right. Well, you talked about smoking being a factor. Is it because it damages the collagen and leads to weakening of the fibres, or is it other factors?

Dr Fariba Willison-Behnia: 8:18

first of all, respiratory problem, chronic cough, and increased intra-abdominal pressure. and nowadays we have more and more, insight into the collagen disorders. POTS is coming up frequently, Marfan syndrome, and the actual smoking, also damages and ages the tissue. So you can see women who are smoking already have, different type of skin to women who are non-smoker. And thank God smoking in Australia has reduced but, even vaping is not better than smoking, so the collagen will be affected. And smoking around a child, it is irresponsible or during the pregnancy is irresponsible anyway. So there is no benefit to smoking, so otherwise we all would have smoked. So it's particularly causing cancer from the mouth, throat, tongue, oesophagus, and, stomach, bladder, and, cervical cancer as well as DVT, which can be life-threatening.

Dr Gavin Nimon: 9:17

Exactly. When we talking about stress and urge incontinence, I presume stress is purely just a leaking, while urges are sort of sensation that have to pass urine in a sudden rush. Is that correct?

Dr Fariba Willison-Behnia: 9:27

Yeah. So basically, when the bladder is overactive or when the woman is very sensitive to the smallest amount of urine, they wanna straight away go to, pass urine. And if they don't, the bladder will, contract, and the, urine will come out. And the way to diagnose those women is that, in the history, when we take a history, we ask them, "When you go to a shopping centre, do you spot where the toilets are? Do you, leak when you put the key in the door? do you leak before you make to, to the toilet? Or when you wash your hands, do you have the sensation that you, need to go to toilet?" So these are, questions that you-- one has to ask, to see if the lady has overactive bladder. An overactive bladder is, a muscle issue. And, again, with losing weight, we can, cure about 80% of these women. and with oestrogen cream, if they are post-menopausal, because sometimes, atrophy of the vagina also causes urgency. And, avoiding caffeinated drinks, any stimuli like oranges or things that are really sour, we have to reduce it. We have to increase their water intake rather than Coca-Cola, and a lot of people are on a lot of fizzy drinks. Then if that doesn't work, then we can go to anticholinergics, but we have to be careful that some of the anticholinergics could cause cognitive issues for especially older patients. I wouldn't recommend Visicare for older patients because of, they have to be able to use their brain function. we have Betmiga, which is very good, but unfortunately, they are expensive medications. But there are Ditropan or Oxytrol patches where patients could have on a lower dose and maybe get it up slowly, otherwise they will have dry mouth and dry eyes, and that is quite debilitating at times. If the patient doesn't respond to two different type of, medication, then they can consider PTNS, which is a tibial nerve stimulation, or they can, have Botox in the bladder, which is-- which we do it once a year. And then, it basically reduces the contractibility of the bladder muscle, and they can pass urine easier. One other thing that I would like to add is that sometimes, women might be in urinary retention, so their, bladder muscle is not working good enough. And, that can happen in elderly women or when they had a, a prolapse or a sling procedure that it is so tight that the urinary retention happens, and then we call that overflow incontinence. It means the bladder has been ex-expanded so much that there's either the bladder has to rupture or the bladder has to contract to get rid of the fluid. So very important that when we see this group of women with prolapse and incontinence, we exclude other causes, other intra-abdominal causes. And th-this is just by, not only taking a history but also doing a vaginal, ex- inspection. And I see that many GP's, have hesitancy to, examine women. And that is really unfortunate because a vagina is just another orifice and another organ, and fifty percent of the populations are, is, are women, and you can't just, stop, treating the women, because they have a vagina. So we ca- we have to get over this problem. It is twenty twenty-six. We should consider vagina as a, organ. And sometimes just as, having a look, you don't have to be a gynaecologist to do the vaginal, examination. Just having a look, you might see there's a cancer sitting on the top of the, vagina. So, most of us have to be able to do a Pap smear. So you can see if the walls of the vagina are good or not. You can see if the labia are abnormal or not. And we can take a swab. We can see that if something else is bulging in the vagina, and the bulge that the patient thinks is actually a tumour or is a cyst or a Bartholin cyst or something else. And then if you can't see anything, then you can send it for the ultrasound, and the ultrasound will identify if this patient has ovarian cancer, and that's why everything is pushed down. Is it a fibroid that everything is pushed down? Is any other bowel cancer or anything else that is causing the problem? So when the woman comes with bulge, it is actually a lot of assessment that can be done by the GP and should be done by the GP. And, if you can see that the damage is at the level of the vagina and at the level of, the rectum, then, the first point of contact would be pelvic floor, physio. But someone, not any physio, a, a physio that is specialised in this area, and they have to show the woman how to do supervised exercises. The physio will put the two finger in the vagina and teach the woman how to do it and will check if the, what the woman is doing is correct. Then they can go home, and they can basically do it themself. Always bring up the weight. I know that weight is a very hard thing to talk about, but if you put it in a scientific way of saying the increased weight causes increased intraabdominal pressure, and that is why we have what we have, then women understand. you can say high BMI or, increased abdominal pressure by excess, weight. And, there are so many, dieticians who are specialised in this area, there are many, injectables available on the market, that one can have. And, the way I put it to women, "Okay, these, injections are expensive, but it reduces the junk food that you buy." And, I write to them, "The coffee that you don't need, the, cake that you don't need, the dessert that you don't need, the iced coffee that you don't need, and all of that." And when you put that together for them, how much they have spent, but little by little, by those kind of junk stuff that is bad for them and increases the weight, and how much they actually save on shopping by, by going on this medication, they will understand. And, one thing is that women always wanna look after other people. when we are mothers, children are the most important thing, husband. and when, around this age also, the parents need us, so we are stretched all over, and then the, us is the last thing that we wanna focus. And as a GP, you should bring the focus on the mother and say, "If you are the care provider to so many people, you have to be healthy. If you are not healthy, you can't provide any, health or any help to other people."

Dr Gavin Nimon: 16:34

the incontinence and the pelvic organ prolapse, do the two go hand in hand or can you have incontinence without the prolapse and vice versa?

Dr Fariba Willison-Behnia: 16:41

you could have thirty percent of people can have just, a prolapse and incontinence together. Thirty per-percent of women can have just stress incontinence, and the rest can have urge incontinence. Urge incontinence is mostly lack of oestrogen. So when women are breastfeeding, or when they go through menopause, or overweight women and women who have a lot of caffeinated drinks. Also, women with MS and neurological problems have, those, urgency and overactive bladders. So you have to be very careful that you take a thorough history when it comes to that. And, really, lifestyle changes are often the first line and the most important thing. With the stress incontinence, it can be alone, as I said, especially in women around age thirty, and a woman can have stress incontinence without even having a baby. So baby is not the beginning and end of these kind of issues. And, the, they mix together. Sometimes the prolapse itself can cause the stress incontinence, or sometimes the prolapse itself, because the bladder is not emptying, can cause urgency and urge incontinence, and when you correct the prolapse, it gets better. Sometimes the prolapse masks the stress incontinence, and when you reduce it, then the stress incontinence is more obvious. So that's why when you send the patients to the physiotherapist, they will do the pelvic floor exercises. They recommend devices that we put into the vagina to help the woman, to gain their quality of life. But also, if it is, a problem with the stress incontinence, it is unmasked, and then when you send them to a specialist, they will perform u-urodynamics. And the urodynamics says at what pressure they have this stress incontinence. Because if it is very high pressure, correcting it will cause urinary retention. So you have to teach the woman to reduce the intraabdominal pressure. And if it is at certain, levels, then maybe we can consider incontinence procedures at the time of prolapse surgery.

Dr Gavin Nimon: 19:16

Excellent. for the GP or registrar looking at one of these patients and assessing them, what are the sort of main questions they should be asking?

Dr Fariba Willison-Behnia: 19:24

Yeah. the-- in the history, first of all, have a template and ask every single woman this question, okay? do you feel you have a bulge in the vagina? Do you feel it or do you see it? Because, when patients are seeing it, it is much higher, stage of prolapse than when they feel it. does it cause discomfort, especially towards the evening, end of the day, But prolapse doesn't cause any pain. So if a woman comes with pelvic pain, it is not prolapse. Prolapse is more discomfort and, yeah, really discomfort that affects their quality of life. Do, do you have to push that bulge into the vagina in order to pass urine or to evacuate the bowel? That is very important. And how much does it bother you? And how long have you had this problem? So these are really important prolapse issues. With the stress incontinence, when you cough or sneeze or exercise do you have any leakage of urine? Is the amount small or big? Because a stress incontinence is little, leakage. With urge incontinence, when you have to go, do you have to go? Do you spot the, toilets in the shopping centre? Do you-- When you wash your hands or put the key in the door, do you have to go to toilet? And, how much does it affect you from zero to ten? So get the patients to tell you how much she affected by. Do you-- Have you reduced your fluid intake? Do you get recurrent urinary tract infection Have you reduced your social activities, visiting friends or getting into coital activities because of this issue? Do you leak when you have coital activities? And these are urge incontinence. And the coital activity, one is at the time of penetration because the prolapse is corrected in penetration and the patient is leaking. That's a stress incontinence. But if it is at the time of orgasm because it is muscle contraction, it is then related to the urge incontinence. So these are really, very pointed questions that help. Also, in twenty twenty-six, we should be able to talk about sex because, having a good, sexual function is not just having fun. It is a part of, health and, it is medically more indicated for older couples than young ones. WHO believes that, wellness and feeling good, happiness has four different, aspect to it. It's like a car with four tyres, but, and one of them is a status, education, emotional well-being, sexual well-being. And we probably have more, the emphasis on our, how rich we are or how we stand in the society and have education, and we very little pay attention to our emotional well-being and sexual well-being. And, so if you consider that you have a car with four tyres, if you have, exclude the sex life out of your life, you are running your car on three tyres. And, it is very important that you bring these discussions and, in-intercourse is not just about penetration. Many men have prostate cancer, may not have, may not be able to have, penetration. Many women may have other problems or may not tolerate penetration, but you have to bring the intimacy back into the, families and, as a primary caregiver, that is your job, and then if it is not happening, then it is my job to do so. But it's very important that you approach the subject. I can't tell you how many women have cried in my office Because no one ever asked them about this, and they are about to divorce, or the husband is about to walk away. And I can't tell you how many men have, cried in my office because the woman thought that the man is okay with those kind of issues, but the men were not okay because nobody had asked them. Assuming people are getting older and they don't need any emotional support, it's wrong. This is our judgment, but it's not the reality. And the reality is that any couples who are sexually active three times per week, they have 30% less, stroke, 30% less heart attack, 40% less being on antidepressant. So every per- person who walks through my office is on some kind of anti-anxiety and, antidepressant. So get them sexually active, and they feel so much better about them. When women get sexually active, they are more confident because the testosterone levels increases. And when women have more testosterone, they have more muscle mass. When we get older, we lose 1% of our muscle mass per year. Get them into the gym, get them into weight training. explain to them why we say what we say. It's not just having fun; it is medically indicated. women who have more testosterone have less brain fog. so if they have any issues, start them on HRT. And if anybody, please, is listening to this, programme, HRT is not as scary as we thought, ten, 20 years ago. The FDA has taken the ban of HRT in November last year. We have now new studies showing how good HRT is for women in terms of their mental health and physical health. Please do not be scared by the, papers that were presented 20 years ago by media before the doctors could actually interpret it for you. there are a lot of women who, are suffering because they have missed out on HRT over the last 20 years. So have a look at it, educate yourself, because you can be a great help to a lot of women who walk through your office.

Dr Gavin Nimon: 25:36

so what are the steps for the examination though?

Dr Fariba Willison-Behnia: 25:38

the, after you do the inspection, it obviously, with permission and patient consent, you do the examination. Please be re-- reminded that one in four of, women have been sexually, a-assaulted as a child. So there is a lot of trauma, there is a lot of un-- unsaid history, there. it is better for you to ask in your history, "Has there been any, sexual trauma? Has there been anything in the past that I should be aware of? Because I am in your team, I wanna help you. I don't wanna bring on, a stressful situation. I am going to have a look." and always have a chaperone to support the woman. I am a woman, but I always have a chaperone. and, and then with permission, show them the speculum. It can be bivalve, it could be Sims speculum. Make sure if it is a metal speculum that's not cold. Make sure the gel that you have on the, speculum is not cold. Just simple stuff that you can pay attention to. Please do attention. And then say, "I'll let you get to use to the temperature." Just rest the speculum at the level of the fourchette, and then gently, advance it into the vagina and say, "Okay, I am opening the bivalve, and everybody will feel a bit of discomfort. If you feel discomfort, it's m-not me not being gentle. I just need to have a look. But please tell me if you can't tolerate it." So when you walk the patient through the vaginal examination, they feel so much better, and they feel that you see them, that you hear them, and if at any stage they cannot comfortably, tolerate it, stop. That is, don't pursue it. Don't say, accept this and tolerate this, and I'm almost finished." no, because it could be the last time that woman will undergo any kind of vaginal, examination. Be very careful

Dr Gavin Nimon: 27:33

Right. Okay, excellent. Well, very important tips there take on board. we're talking about pelvic organ pro-prolapse. Is there a way of classifying them and staging them And how, what should we think about when we're looking at them?

Dr Fariba Willison-Behnia: 27:44

Yeah. So if, top of the vagina comes down, so we call apical prolapse, which is the uterus or when it's a hysterectomy, the vault comes down. if the bladder is descending into the vagina, we call it anterior vaginal vault prolapse. And if the bowel is protruding into the vagina, it is, posterior, vaginal vault prolapse. And we basically have different staging that we, classified by POP-Q, Pelvic Organ Prolapse Quantification, System. so when you get my letters, I say POP-Q stage one, two, three or four. basically stage one is no prolapse. stage is, two is mild to moderate, three is moderate, and four is severe when it is the whole vagina is inside out. but all of them, you have to give the patients the option of physiotherapy and pessary. Not everyone needs, surgery. We only do surgery on women who are symptomatic. Okay? So if you do a a Pap smear and the woman has a bit of, prolapse, and even if the bladder is coming to the level of the vagina, you ask them, "Do you have any issue? Do you have any, bulge? Do you have to push it back in? do you have any recurrent urinary tract infection?" Because, obviously they cannot empty their, bladder. And if they say, "No, I don't have any of those issues," you don't need to refer her for surgery. You just refer them to pelvic floor, person, and you say, "It's better to pr-protect the, pelvic floor by not lifting too much and correcting constipation, weight, and so on." And you will be amazed how many women actually don't need any surgery if you do the right thing. And, those who do need surgery, then they will be referred to us. However, you cannot decide who is symptomatic and who is asymptomatic. You can't say because a woman has a stage two should not have surgery, but a woman who has a stage four should have surgery. If a woman has a stage two, prolapse but has symptoms and cannot engage in sexual activities because she is embarrassed, she has no sensation, or the partner has no sensation, and they have given up on intimacy, then send that patient for further, evaluation and potential treatment

Dr Gavin Nimon: 30:37

Right. So pelvic physiotherapy and the women's health physiotherapists are very useful, in, adjunct to your treatment of these patients

Dr Fariba Willison-Behnia: 30:45

Hundred percent. I don't operate on any woman unless they have seen a physiotherapist for three months. That is a must because after the, surgery, they have to continue with pelvic floor exercises. So it's not just before surgery. So we prepare them, and then often they say, "Oh, my symptoms have resolved. Okay, so I don't need to do surgery." And if they undergo surgery, then I continue to ask them for the success of the surgery to continue with their pelvic floor exercises that they have learned preoperatively

Dr Gavin Nimon: 31:19

So very much like musculoskeletal in that sense, prior to shoulder surgery, I'd always been recommending physiotherapy and post-surgery as well.

Dr Fariba Willison-Behnia: 31:26

Yes

Dr Gavin Nimon: 31:27

obviously the difference will be though that the number of women's health physiotherapists are probably a minority compared to musculoskeletal physiotherapists, and, hopefully they're increasing in number and I I plan to do an interview with a women's health physiotherapist in the near future. what else apart from exercises will they be talking about too, and what do you ask the physiotherapist to do?

Dr Fariba Willison-Behnia: 31:47

The physiotherapist will assess a woman, and, they will teach them, for example, if they do a lot of lifting, how to engage their whole core muscles and how to, lift. they teach them how to go through the life, with support rather than just going and picking something up. women can lift hundred kilos or sometimes two hundred kilos and not have a prolapse because they know how to engage their pelvic floor before they lift something. So these are very important. They will also talk, physiotherapists are a bit gentler than surgeons when it comes to weight and comes to, other lifestyle. They have more time, They give one hour of education. The doctors have to do it in this one hour, history taking, examination, education, and so on. That's why, really good doctors have nurses, incontinence nurses in their, company that sits down for one hour and takes the patient through it. And we give also materials to the woman because when they come, they only absorb twenty percent of the information given to them. It would be nice for them to have some links to go and have a look like RANZCOG or, Australian Urogynaecology Society websites, and, they basically refresh their mind, about what was said to them. And we get our nurses to go through everything that we have said and put a tick in front of it. It means that we have mentioned all of this. And then when they read it again, they say, "Aha, okay. yeah." The patient pamphlets are really important. And I would recommend that every GP should have some pamphlet in their office because sometimes the women are Embarrassed to talk about it, but when they go and see the pamphlet and it says, "Sixty percent of women have this problem over their lifetime," then they don't feel special anymore. So the majority of women have this issue rather than not having this issue. It's very important for them to understand it's a very common problem, but it is still a taboo subject in twenty twenty-six. And I think, Gavin, one thing that I wanted to say is I think this is the fault of us women because we fall pregnant, the baby is for nine months in our tummy, we carry the baby for two years in our breastfeeding education. So what happened? Something has failed at the very beginning of life, educating our boys and girls that these situations are okay. So if any of women are listening to me, tell your child that you have a urinary issue at early child. Get them involved to help you."Can you help mummy? Because mummy has this issue." And then it is not a taboo subject. Let's break the taboo subjects from inside the houses when the children are little, so then, they understand what problem we as women are going through. Our partners understand that we gave the gift of a baby to them. They didn't contribute much, but they can contribute to our recovery, and then we are not so isolated and left alone. So let's start the conversation, at a woman, centred first, and then, GP's can help also to educate the women who are a bit older and hopefully in near future we don't have this problem as a taboo subject.

Dr Gavin Nimon: 35:06

Yeah, I realised how common things were when I-- I'd heard the expression all my life but never really thought about when someone said, "Oh, I laughed so much I peed myself." And, I was speaking to the women's health physiotherapist, and she mentions that, that's where it comes from, and it's actually a common issue d- despite the age of the patient. And, it's actually a reality of what happens, and so people need to take this into account.

Dr Fariba Willison-Behnia: 35:27

Now, I wanted to say that, a lot of men also have incontinence when they have prostate cancer, and it seems that we talk about that much easier than about women because, the society is still a bit paternalistic. So we have to overcome those issues by education. And, women We are creators. we should be proud of ourselves that we can fall pregnant, we can give birth to another human being. It is miracles. It is fantastic. Why are we embarrassed about something so beautiful that we do because we have a little bit of damage? That little bit of damage doesn't, describe us, as damaged, pelvic floor or incontinent woman. We are creators who have gone through a little bit of difficulties because we have given birth to this beautiful child, and that is all reversible. We can help that. We can overcome all that problem

Dr Gavin Nimon: 36:22

We mentioned pessaries as well, which was what something, a non-operative technique. What actually is a pessary and how does that work?

Dr Fariba Willison-Behnia: 36:29

Pessaries were used, over many centuries, and if you go to Louvre, you will see a painting there that a man is inserting a pomegranate into a queen. So, so basically using a device to insert into the vagina, not allowing the organs to descend into the vagina. And thank God we don't have those kind of devices anymore. We don't have to put a pomegranate in. Now there are, basically very soft and malleable, devices. some that we can have intercourse with, some that we have to remove to be able to have intercourse, some that has to be managed by physio or by a specialist, and some that the patient can do it themself. And, we, we-- In discussion with woman, you decide one upon the other. So basically, there are devices that they hold everything back together. And if the woman has a stress incontinence, some of them come with an, especially the ring pessaries, come with a knob that press against the bladder neck, and they don't, leak any, urine. And they can take it out every night when they go to toilet, and they can insert it every morning. With ring pessary, or, mushroom pessaries, you can leave it in for three months and remove it, and, you can, with the cube pessaries, you can leave it in only for two weeks. So de-depending on what shape you use and what kind of prolapse, and how severe your prolapse is, we use different kind of devices.

Dr Gavin Nimon: 38:02

Right. when these measures fail, you've tried the physiotherapist, you've tried pessaries, and things aren't quite right. You've still got a prolapse or you've still got some incontinence issues. what is the next step? You'd mentioned surgery. What are the different types of surgical techniques that are used?

Dr Fariba Willison-Behnia: 38:16

Okay. only 10 to 20% of women seek medical advice. and, that's very important that a lot of people are suffering in silence because we haven't started conversation at the GP levels. So out of those 20% who get, surgery, they have native tissue repair, which is basically, what tissue is damaged, we stitch it back together. And you can imagine, depending on the, menopausal status, depending on the quality of the tissue, also the surgeon who performs the procedure. So a surgeon who does this every single day has different outcome to the patient than a surgeon who does five, six per year. And, material that is used and aftercare, and preparation of the patient before and after surgery matters. So we call it in terms of native tissue repair, we have up to 30%, in some cases 50% failure rate. So a lot of women also think, "Okay, why do I have to do a surgery that is no good?" So that's why mesh were, really, we thought that mesh would be the savior. it has helped with the hernia, so let's use it in the vagina. And unfortunately, the unskilled, surgeons, chose the wrong material of, mesh and, the patient selection was not good. some women were very young when they have received the mesh, and it was in the primary, closure of the, or repair that they used. And a lot of women had major complication. Unfortunately, we have a lot of survivors that have to cope with the pain and discomfort, bleeding, painful intercourse. Even the word hispyronia came to the literature because men had pain at the time of the, intercourse. Some of these women are, wheelchair-bound and, unfortunately, some of the research were not published properly, when the product was introduced, and the companies probably pushed the product really harsh. And that's why the regulatory bodies withdrew the mesh from the market in 2017, '18 And that left a big void in, women's health. with that, slings that we use for, stress incontinence or abdominal mesh that we use for, prolapse surgery also got affected because everybody was scared of the word mesh. so now we have to apply for TGA, case by case, to be able to use the mesh, abdominally. And, I wanna acknowledge all those women who had, mesh and had problem, but we have a lot of women who also had mesh and had successful surgery. So I hope that the, the new research into new areas is so thorough that regulatory bodies are looking at it with microscope and, make sure that, all the complications and everything else is, reported before a product goes into the market. But nowadays, that, withdrawal of mesh has forced our hands into a lot of research and, certainly I've got very interested in cell therapy and so on. And there is a lot of development and innovation in terms of regenerative medicine. It's a very big hot topic out there because it is patients' own blood, it is patients' own cell that we can manipulate and use it before and after surgery or at the time of surgery. There are a lot of, graft and so on developed and which are showing promising effect. and we are also using patients' own, body tissue like fascia lata. we can, in basically cut a small incision in the patient's thigh and harvest some of the fascia lata and use it abdominally or under the bladder neck as a, sling. also we have cadaveric, product available to us, but a lot of women again, don't like, cadaver products. Some do, some don't. So that is a conversation that we have. But to answer your question, we have native tissue repair. We have no more, mesh in Australia available on the market for vaginal repair, but we do have it for sling and abdominal, prolapse surgery, laparoscopically or open. But that has to be in the hands of people who do them every day and people who are certified to do them. And in terms of ordering mesh for, sacrocolpopexy, it has to go, through TGA. It means they are looking at it properly and, it is, it is not difficult, but it is very much regulated.

Dr Gavin Nimon: 43:02

So they use a, a structure, whether it be a native tissue, cadaveric tissue or a, a artificial tissue to suspend the actual organs back up to the sacrum.

Dr Fariba Willison-Behnia: 43:14

So top of the vagina or the uterus get attached to the uterosacral ligaments and, sacrum. often we can do it robotically, laparoscopically. Now some older, colleagues might even do it, open surgery. but a lot of vaginal, surgery happens at the same time, so we like to talk about laparovaginal approach to pelvic floor, repair. So, that we, basically vagina is like a cylinder, and we have to attach all the aspect of the, vagina, to its right, structure for that to, help. You cannot do vaginal surgery and not support the apex. It is very important that even if it is prophylactically, the apex is supported, because, otherwise things could, come down. The woman doesn't understand that, "Oh, I did, your prolapse surgery at the back of your vagina, but now the the top has come down." The woman perceives it, I had a bulge when I came to you, and now I have a bulge again." So if you see any weakness in other compartments, especially apical, you better correct that, otherwise, the bulge is bulge to the woman. It's not like your job, Gavin, that my right shoulder is he- painful and now my left shoulder is painful. So, the vagina is just something that is, "I have vaginal bulge." So, we have to be careful in terms of which part of it we are correcting.

Dr Gavin Nimon: 44:42

So the previous ones that failed with the mesh were transvaginal placing mesh to support the posterior wall of the vagina to the ligaments. And nowadays you support with native tissue or other substances both, laparoscopically and d- and transvaginally if necessary.

Dr Fariba Willison-Behnia: 44:59

Sure. we had vaginal mesh that we didn't even go laparoscopically, and we could attach the, front of the vagina and back of the vagina to the top of the vagina. And because the systems were made so easy in engineering-wise, too many doctors got involved because it was easy to do. So, but their skills were not, very difficult, but their patient choice and so on was. so, the laparoscopic, mesh sacrocolpopexy is a level six laparoscopic surgery. Not every gynaecologist can do them. They have to go through s- certification or, working in higher volume places to learn those kind of skills. Both of them can fail. The sacrocolpopexy mesh can fail. The sacrocolpopexy, cases, that is for the top of the vagina, can erode into the bowel, can erode into the bladder, or can erode into the vagina. Also, the vaginal meshes can cause problem. so both of them could cause problem. and but the vaginal mesh is completely out, and we have more understanding how to use mesh. We are using lower weight mesh, and we don't put mesh in at the time of hysterectomy because there is a wound on the top of the vagina. Vagina is not a clean organ. We are dealing with, bacteria, which are necessary. They are not dirty, but they are necessary bacteria for the vaginal health. But those bacteria are not sometime compatible with the meshes, and, they can cause infection, fibrosis, erosion, and other complications. So, if we do hysteropexy, which means lifting the uterus up… by the way, not every, pelvic floor repair requires hysterectomy. If the uterus is normal size, we can keep the uterus in, and we can anchor the uterus to the, suspensory ligaments, either uterosacral ligament or, sacrospinous ligament or uterus and the, sacrum. But if it is, a large uterus with fibroid and potential, problem with cervical screening or, polyps or, what-- that makes a uterus more than ten weeks gestation, it's better for the uterus to come out, and then the top of the vagina is anchored to, the ligaments or sacrum

Dr Gavin Nimon: 47:29

Okay. So it all relates to the collagen deficiency, and obviously genetic factors will be a major factor in that too.

Dr Fariba Willison-Behnia: 47:37

they-- I imagine a cervix, which is one or two millimetres, has to dilate to something ten centimetre. So it doesn't matter how good your, collagen tissue is or fibrotic tissue is, that quick expansion and extension of those fibrous muscles, some of them will break down. And also, doesn't matter how strong those suspensory ligaments are, by the woman pushing for two hours for that baby to come out, so some of those ligaments are torn. So that's why it is very important for you to diagnose at the time of surgery where the break into the suspensory ligaments are, and then you go a step, a little bit higher to, suspend the uterus. And, If you use those damaged tissue and you just put couple of sutures, the woman has a one constipation, and that comes undone. So that's why there is a lot of skills, and it is up to the GP's and up to the women also to have a look who's, who does this every day, and then go to those specialties to get this corrected.

Dr Gavin Nimon: 48:47

Excellent. what success rate should a, a woman expect to get after these scenarios?

Dr Fariba Willison-Behnia: 48:53

There is no guarantee to any prolapse surgery because there are so many risk factors, and some of the risk factors are collagen deficient. I could be the best surgeon in the world and, I could do the best surgery, but the prolapse fails, because, the collagens are not there. the woman is smoking, is a chronic cough, pe-- chronic, respiratory issue, chronic constipation that nobody can help. So success rate is seventy to eighty-five percent. So very important, no guarantee. also very important to understand that, if you have a proper pelvic floor repair, your activities should not be limited. You should be back to normal activity. You should be able to go to gym, but with some modifications. So I tell my patients, "Don't do the weights standing up because we have a hole in the pelvic floor called vagina, and the gravity is not our friend. Sit down in a reclined position and do your weights." so when you do, abdominal exercises, do part of it with the upper body and part of it with the lower body. And when you do pelvic floor, and when you do work with physios, ask them to see how you activate your, pelvic floor levator muscles and make sure that your core muscle is good. So they can go back to jogging, they can go back to fast walking, gym, and all of that. The one thing that is not good for pelvic floor is when you are jumping. If one foot is on the ground all the time, there is no effect on pelvic floor. But if both feet are not on the floor, that is where the problem happens. So reduce those kind of activities and you should be fine.

Dr Gavin Nimon: 50:36

And there are other, measures too, I presume. say the patient's gone through all the measures and unfortunately they've still got some urinary incontinence. What can they go to the chemist shop for and ask for to help them through,

Dr Fariba Willison-Behnia: 50:46

Tampons a lot of older women never have used tampons, but it is very easy to, to learn to do. use oestrogen cream. I throw oestrogen cream at everyone, so I don't even worry about breast cancer. I know that a lot of oncologists and, GP's are. The absorption of, oestrogen cream is very little. the benefit of it is much higher than recurrence of breast cancer. So, and a lot of breast cancers are not oestrogen, receptor positive, so please do not scare the women of using it. And if they can't use that, maybe consider Intrarosa because some people might be allergic to oestrogen, pessaries. So vulva care is really important, and one of the most important thing is do not wash yourself with soap. Avoid soap. At night, don't wear any underpants. the G-strings have been the worst thing that ever have happened to women because that they are really bad. The polyester underpants, they are beautiful, but very unhealthy for women. So go back to cotton, underpants, and at night, don't have any nighties during the day if you can avoid. Long skirt, no nighties, and let that area air. these are really important things that women can do in terms of vulva care. And if you put everything together, you will be seeing how more comfortable women are. But definitely there are a lot of incontinence underpants that women can wear. they can wear, certain, pads for incontinence. There are even, some period underpants that, can catch the small amount of urine and women can be comfortable. So but definitely tampons is the way to go

Dr Gavin Nimon: 52:25

Brilliant. Well, any take-home messages for those listening, general practitioners or medical students coming through the ranks?

Dr Fariba Willison-Behnia: 52:33

Please see the woman as a whole. So don't separate the woman from the rest of the population because they have a vagina. Ask them the question about it. Sexuality is important, and all of you have been, born through a, organ called vagina or 10 centimetre above it, that is caesarean section. So, and all of you have a woman that you love, either as wife, daughters or sisters, or you're a woman yourself. So let's end the taboo subject in 2026 collectively.

Dr Gavin Nimon: 53:09

Brilliant. Well, thank you very much. It's been great having you on board on Aussie Med Ed. We look forward to, speaking to you again to talk about another important issue, such as female genital mutilation, which we'll talk about that, which has affects many people. Thank you very much.

Dr Fariba Willison-Behnia: 53:24

Thank you. Gavin

Dr Gavin Nimon: 53:25

Thank you. A huge thank you to Dr. Fariba Behnia-Willison. If there's one thing to take from today, it's that leaking and prolapse are common, but they're not something that women simply have to put up with, and the conversation can start with a single question in a GP consult. For more information, the Continence Foundation of Australia and National Continence Helpline is on 1800 330066, and Fariba will be back soon for a very different and very important conversation about female genital mutilation. Until then, thanks for listening to Aussie Med Ed