Kim Vopni (00:01.24)
Hi, Lise. Welcome to the Between Two Lips podcast. I'm happy to have you. You that had reached out or somebody on your team reached out and recommended you as a guest. And I'm really glad they did. I'm excited to learn a little bit more about what you do in the world of urology. And we're going to talk about all things incontinence. We're going to talk specific, maybe some differences about postpartum incontinence and other phases of life.
Aleece Fosnight (00:21.144)
Okay.
Kim Vopni (00:30.104)
But before we jump in there, can you please give us a little intro as to who you are and what brought you to the field of urology?
Aleece Fosnight (00:38.628)
I would absolutely love that. And thank you so much, Kim, for having me. I think actually one of my team members at Aeroflow Urology was the one who reached out. And I definitely have been a little bit of a fan girl of yours listening to your podcast and watching it on Instagram. So this is a super treat and I'm very excited to be here today. So, but yeah, my name is Elise Fossnight. I've been a PA, a physician assistant for almost 14 years now, which is just hard to believe.
Kim Vopni (00:55.197)
Cool.
Aleece Fosnight (01:08.582)
The way that I got into urology was actually when I was in PA school and I was trying to figure out what I was gonna do for my master's thesis and I really loved women's healthcare at that time and it's funny that a Viagra commercial came on the television and I was like, oh my gosh, if there is a blue pill for men, there's got to be a pink pill out there for women and this was 15, almost 16 years ago and there was nothing at that time. So it kind of pissed me off and I was like, well we
we should dig into this. And when I started looking at the research, a lot of the women's sexual health articles were coming from urology journals. And I had actually worked with a urologist when I was in high school. So I was like, well, maybe this is my calling. So I started doing that as my research. did a urogynecology rotation and loved it. And that urologist that I had worked for when I was in high school actually caught wind of what I was doing. And he said, hey, do you want to come back home and do female urology and female sexual health? And I was like, absolutely.
Absolutely sign me up. Let's go. So that's kind how I got into it and I've been doing urology ever since. I have a specialty in sexual medicine. I opened up my own private practice five years ago, really focusing on pelvic health and sexual medicine for everybody. So I do see people with penises and then I also do some gender affirming care and talk about the importance of their pelvic health as well.
Kim Vopni (02:12.504)
Cool.
Kim Vopni (02:32.766)
Mm-hmm, very cool. Okay, so what would you, how would you define sexual medicine? Let's start there.
Aleece Fosnight (02:40.302)
that's a really good question. So sexual medicine for me is a field of medicine that focuses on the sexual functioning of an individual. And that can range from all of those facets of the sexual response cycle, from sexual desire to arousal to orgasm to resolution, but then also pain. So I do see quite a few folks with pelvic pain that is associated with sexual activity, but it also for me goes beyond that and also includes hormones.
and how that actually impacts someone's overall health and wellbeing as well.
Kim Vopni (03:14.99)
Okay, so I kind of planted that seed on purpose because I want to work we're diving a little bit deeper into incontinence, but I want to I want to bring it back there in a moment. So from an incontinence perspective, there are different types of incontinence. So first, can you define what is incontinence and what would be the different types of incontinence that somebody could deal with?
Aleece Fosnight (03:25.809)
sure.
Aleece Fosnight (03:37.817)
Yep, absolutely. So incontinence is the fancy medical term for urine leakage. And we think about it in terms of when you're leaking urine when you don't want to, is the biggest thing. There's going to be four big types of urinary incontinence that we see out there. The one that a lot of people think about is stress urinary incontinence. And that's when you leak urine, when you cough, sneeze or exercise. And that's when the abdominal pressure overcomes what those pelvic floor muscles in your pelvis can actually
do opens up around that urethra and boop you leak urine right and then the other one is going to be urgent continence or a lot of people know it as overactive bladder when you feel like you really have to go to the bathroom and you're on your way to that bathroom and you actually leak urine on your way over to using the restroom what that's happening is the bladder muscle or the detrusor muscle is squeezing and missing that signal of like wait I'm supposed to be there at the bathroom but but I'm not quite there yet
So you might leak a little bit of urine there as well. The third one is more of a mixed type where it's a combination of both stress and urge incontinence. And then we have overflowing continence where your bladder is so full that it's overflowing. I often tell people it's like if you take a glass of water and you go fill it up at the sink, right, and you're filling it up and you keep overflowing and your because your bladder and your cup can only hold so much. There is kind of a fifth one too. We talk about functional incontinence.
So people with mental health impairments, that could be from a traumatic brain injury, MS, Parkinson's, Alzheimer's and dementia. Those can be where they don't have that awareness anymore of understanding when they need to go to the bathroom and their bladders just, they'll just use the restroom. So kind of, so four types mainly and then we have that fifth one that kind of ropes in there too.
Kim Vopni (05:29.964)
Got it. So now in. Let me see which way I want to go first. guess let's let's go down the postpartum path and then I want to come back to how we address the different types. So what it's very common and especially in the first few weeks postpartum especially after a vaginal birth but it can be after after cesarean as well. What if anything is different about postpartum incontinence compared like with
Aleece Fosnight (05:35.533)
you
Yeah.
Aleece Fosnight (05:42.232)
today.
Kim Vopni (05:59.756)
within those brackets or buckets that you just explained, where would postpartum incontinence fall? Could potentially be in a couple of them. And then we'll go down the path of what we do about it.
Aleece Fosnight (06:07.022)
Mm-hmm.
Yeah, absolutely. So when you think about postpartum incontinence, I often think of it in those first three that we talked about, right? So stress incontinence, urge or overactive bladder or a combination of both. And while super common is what I always tell people, that's not always normal. You know, it's really interesting. I did my Eurogynecology rotation in PA school, actually over in Europe and England, and they do things so different over there. And I'm so glad that I had that experience because they really value pelvic health.
there way more, especially when it comes to pregnancy and postpartum. And so when you're thinking about the way that postpartum stress incontinence happens, right, your pelvic floor expands over 200 % getting ready for this baby to be delivered. Whether you're going to have a vaginal delivery or a cesarean, your body is still preparing for that process. So what happens is this pelvic floor muscle just stretches out and it has more weakness in that area. So any movement you make or bending over increases
that abdominal pressure and those pelvic floor muscles just can't help to support that bladder or that urethra and so urine is going to leak out from that. And so learning to pull those pelvic floor muscles back together postpartum is going to be really important and that's what they value a lot over in Europe is getting you immediately into like a pelvic floor physical therapist, learning about your pelvic floor right away. Where here in the United States we have a little bit of a different view and perspective on that. We're getting better but we have lots of opportunities but a lot
people don't know about their pelvic floor and just don't have this awareness of what's really happening during that. Now with urgent continence or overactive bladder that typically is more related to a nerve that you're actually going to be potentially has had some trauma or injury during childbirth whether again vaginal delivery but mostly during a cesarean that you're going to see a lot more of that overactive urge I got to go right now and the reason for that being is your muscles in your core with your abdominals are also really
Aleece Fosnight (08:09.77)
important to your pelvic floor. And so if we're thinking about the abdominals tying into your pelvis and you just had a big cut open, slash through those abdominal muscles, it's going be really hard and difficult for those muscles to engage and help to support your pelvis as well for that. And so we tend to see the pelvic floor muscles, which yes, they expanded, but no baby actually came through that vaginal canal. And so those muscles tend to overcompensate because of the weak pelvic form or weak abdominal
muscles and are tighter and those tight pelvic floor muscles are going to cause overactivity of that bladder as well. And I talk about this all the time, the difference between tight and strong muscles, right? This is very confusing out there in the world. We think that tight is the best, right? And I hate that word, but we have to think about it strong, right? Tight is going to be really short contracted muscles that don't have much movement, right? Whereas strong muscles are going to be more in the neutral relaxed state where you could, you know, squeeze them and
and use them to what you need to, but they're not weak. And we often see more weak pelvic floor muscles and tight muscles at the same time.
Kim Vopni (09:16.91)
And one thing that you bring into your practice when I was looking through your website and preparing for the call, and you've also mentioned is hormones and something that I talk about a lot is postpartum, where we have we're kind of in this now low estrogen state, even pre menstrual low estrogen state, and then that kind of giving us a little glimpse into
Aleece Fosnight (09:28.173)
Okay.
Kim Vopni (09:43.874)
what we're going to be facing when we reach menopause in kind of that forever low estrogen state. So that's, am I right in assuming that's playing a role? And do you suggest or recommend people use vaginal estrogen postpartum?
Aleece Fosnight (10:02.871)
gosh, so many things.
To go into that, and I love this question so much because I do think that so much of the fear behind hormones has trailed, brought through us from the Women's Health Initiative and things like that, but we are definitely as a medical community and society really embracing more of what are the benefits of hormones and what they do. So when you think about in the kind of postpartum timeframe of what's happening, you're having adjustments of hormones from being pregnant for,
nine months, ten months. And so it's that swing that definitely could do that because I want to also be cognizant of the fact that not everybody decides to breastfeed or lactate afterwards. And so just being postpartum in this first couple of weeks can definitely cause some hormonal shifts and some vaginal dryness in that area. Now let's layer in breastfeeding on top of that, which we think about that feedback loop and that signaling, right, increases a lot of that prolactin in your body, which is an inhibitor of ovarian function.
So buddy, you are going to get some dryness in those genital tissues. We actually have a name for it now and it's called Genitourinary Syndrome of Lactation. And so it's really exciting that we've actually recognized it, named it and are valuing that this is an important topic that we should be talking about. So yes, can vaginal estrogen be something that you can apply postpartum? Absolutely. I always tell people I recommend talking to your health care provider before you start using a friend's estrogen cream or something like that.
that because buddy people are known to do that. But just make sure and make sure that tissues are healing right we know that trauma can happen during the vaginal birth and again even through a Mississarian. So I want to make sure that those tissues are at least ready to receive that local estrogen and that something can be placed in the vagina to do that. So yes you can do that vaginal estrogen and a little bit goes a long way. Anywhere from two to three times a week is all that you have to do to apply it. Your finger is your best tool. I tell people blueberry size amounts
Kim Vopni (11:58.04)
Mm-hmm.
Aleece Fosnight (12:05.158)
use what I call this swoop and swoosh kind of movement where it's going into the vagina and just 360 it around and come on the outside too. That can be really helpful. Now I do caution with some folks that are lactating or chestfeeding, breastfeeding, that to be mindful that this could potentially affect your milk supply. While we know that the majority of that vaginal estrogen is staying local, some of it can get absorbed systemically and potentially impact that. So just be mindful of that as well.
Kim Vopni (12:08.974)
Hahaha
Kim Vopni (12:34.294)
Okay. Is there, do you have a preference between estriol or estradiol or bi-est?
Aleece Fosnight (12:34.893)
Yep.
Aleece Fosnight (12:41.044)
I'm an estradiol girl. I want that E2 formula of that estrogen in your body, which is what your body makes during the, in your reproductive years, right? Estradiol, yes, is great. It's definitely during your pregnancy timeframe, but those vaginal tissues are going to respond a lot better to that E2 estradiol. Yep.
Kim Vopni (13:01.56)
Yeah. Yeah. Okay. Yep.
Aleece Fosnight (13:03.864)
And then you can talk about DHEA. So we have Prosterone, right? That's out there too. And I'm a big fan of Intra Rosa is that brand of that one. But Prosterone is going to be great because that's your precursor with DHEA to testosterone and estrogen. And we forget, right? That women have five times more testosterone in their bodies than they do estrogen. And that you have those testosterone receptors in those genital tissues and those pedigree muscles, which is really important, right? To build that strength and to layer in that tissue also. We also found that DHEA
has increased nitrous oxide properties to it and nitrous oxide is really important right for vasodilation and bringing blood flow. When you bring blood flow to those tissues you're increasing oxygen to them to keep them happy and healthy and again I'm sexual medicine so anytime that we can get blood flow to the genitals we're always excited about that.
Kim Vopni (13:49.708)
Yeah. Okay, I didn't know that about that. But DHEA and so my understanding with interrosa, it is an ovule, as opposed to a cream, it's inserted and I understand it to be daily as opposed to a couple times a week. Is that accurate?
Aleece Fosnight (13:58.277)
Mm-hmm.
Aleece Fosnight (14:05.87)
So when we think about in the treatment phase, so somebody's coming in, they have dryness. You actually kind of, what I call, do it like a loading dose, essentially, right? And so for estrogen cream, estradiol cream, you're gonna use it every day for two weeks, and then you can back off and use it for two to three times a week. For yes, the press around for the insert one that is there, it is a daily one. That's what was studied in the research papers for it.
but beyond that you you can use your imagination if you really wanted to. So it all just depends on where people are at and what their needs are. So maybe you use the insert you know every day for two weeks and then you back off just like you would for the estrogen cream and do it two or three times a week. I think it's really important to individualize the treatment and focus on what that patient's needs are. Some people like it every day. It's really easy to do it if some people feel like it's too much to do every day. You can always cut them in half and just use half a suppository.
And so again, it just depends on what that need is for that individual.
Kim Vopni (15:09.91)
And is there any reason why somebody could not use both? So DHEA on a few nights, estrogen on a few nights, or estrogen externally, DHEA internally?
Aleece Fosnight (15:13.338)
yeah.
Aleece Fosnight (15:19.448)
Yep, gotcha. Yeah, I mean, you can definitely get creative and use it that way as well. I think about people's dexterity or positioning and can you get to those areas? And so sometimes it is easier for just an insert to be able to pop that in there. And then sometimes it's nice and easy to do a cream. We have to remember where the receptors are. And so when you're thinking about estrogen receptors on the outside can be really good, but the vestibule, right, or that bad, opening to the vagina is actually going to have more of those androgen testosterone receptors.
So for that DATA and that Prosterone suppository, when you insert it a little bit, kind of keeping it closer to the opening so that it'll spill out can be helpful. yeah, whatever. And again, cost, right? We have to think about cost and is this something that insurance is going to cover? The Prosterone, the suppositories can be a little bit more expensive. So estrogen cream by all means is definitely a great option for those folks too.
Kim Vopni (16:17.058)
Yeah. Do you think this is just a sidebar now because you mentioned you've worked in England, but they do, they have over the counter vaginal estrogen and I kind of hope that that happens here. Not kinda. I really hope that it happens here. Do you think that there's like, what do think the chances of that happening would be?
Aleece Fosnight (16:20.612)
yeah!
Aleece Fosnight (16:26.474)
I know. Yes.
Aleece Fosnight (16:34.702)
my goodness. Well, ugh.
I'm always my glass is always half full. And so I'm always very optimistic and hopeful. Yeah, that we're gonna get there. And I think that with the amount of research that's coming out to support the safety, right? I think that that's where you're gonna have to get that buy in from the companies, the FDA to say, yes, this is safe for the majority of people. And we know that now. And so it's, I don't think that it's not a question of if, I hope it's a when, when will it become a
Kim Vopni (16:38.926)
Yeah, hopeful.
Kim Vopni (16:50.478)
Yeah.
Kim Vopni (17:06.53)
Yeah.
Aleece Fosnight (17:07.238)
available, you know, we're getting birth control of, you know, available over the counter now. And so yes, it makes sense that we should be able to have an estradiol cream too.
Kim Vopni (17:14.978)
Yeah, yeah, and I think right now what I view the first step is the the unboxing menopause campaign where they're looking at changing the labeling. So I think that's going to be the first step. And then once that happens, then, you know, it seems like a logical next step that somebody will start a campaign for and we'll get behind and then hopefully it happens. So
Aleece Fosnight (17:21.314)
Yes.
Aleece Fosnight (17:31.65)
Yeah, I don't think that there's many products that with black box warnings on there that they approve this for over the counter. So yes, that strategy of getting that off. I mean, that should have been off many, many years ago, but that's a whole nother podcast topic for us. So.
Kim Vopni (17:34.794)
Yeah. Yeah.
Kim Vopni (17:41.91)
Yeah. Yes. Yes. Yeah. Okay, coming back to you had mentioned, you know, even if somebody was to have a cesarean, there's this preparation that the body goes through and the pelvic floor goes through anticipating a vaginal birth. And something that you know, I've always been proactive minded to how can we try to step in or intervene before challenges happen? So what could somebody do before they get pregnant or while they're pregnant to help
reduce or eliminate that risk? Obviously we can't 100 % guarantee an elimination of it, but how can we reduce the risk of postpartum incontinence?
Aleece Fosnight (18:19.608)
Yep, absolutely. So the biggest thing is to go get your pelvic floor checked, right? Sign up even before you're pregnant. I always tell people and I kind of wish this. have three kiddos and while I'm in this space and I know so much, I wish that I had actually gone to a pelvic floor therapist before and during my first baby. I went afterwards because I was like, well, that's what you do. But I think that I would have had so much more insight to my body that we could have prepared things maybe just a little bit different. I'm super short.
nice big old babies and so my core, my abdominals, like, so there's things that you can do to work on that piece of it. I think that the misconception and I've talked to actually quite a few obstetrics and gynecologists on this because they're like, it's a waste of time to do pelvic floor PT while you're pregnant. And I'm like, wait, but where is that? Where is that coming from? Why are you saying that? There's so much that we can do to prepare the body and there's so much accessories that we can use, right? I had an SI belt to help.
me to stabilize my pelvis during this time, right? We use KT tape to help when my belly was too big for the S-sized belt anymore and I couldn't wear it anymore. So, you know, I think that we forget that there's all these tools that we can do and I actually think that's really great in preparation for delivery. Again, whether you're having a cesarean or a vaginal birth, it's being able to understand your body. How is it opening? Maybe what the best position for your birth could be. I mean, my gosh, what if we can empower women to
be in a position to deliver that they felt good in their bodies, that they felt control over it, and that they had that conversation ahead of time, right? Like, what a world. Yeah. And so, yeah. So get in, even if, like I said, before you're even pregnant, get in for a pelvic floor therapist. I think it's just really good to know your body, what's going on. And you may actually have some dysfunction or imbalances or misalignment in your pelvis that if you address it now, could actually be super beneficial during pregnancy and then afterwards. And then
Kim Vopni (19:58.827)
Yeah, yeah.
Aleece Fosnight (20:19.258)
yeah, go to that pelvic floor therapist during pregnancy. There's a lot of things that are going on. know, your joints are becoming a little bit looser. So is there something that you can do in terms of braces, supports, anything like that can be really helpful. And then you've made us really cool relationship with this pelvic floor therapist. And now you get to go see them afterwards, right? I think it's really important. And when we talk about isolating and strengthening and engaging that pelvic floor and core, right? I will tell you that probably
anywhere from 40 to 50 percent of the patients that I've seen and I've asked them to engage their pelvic floor when I've done a pelvic exam and nothing happens and they're like I'm squeezing right and I'm like no nothing's nothing's going on so again it's that I want if anything if I can create that connection between that mind and body to be able to help them you know engage and pull up those pelvic floor muscles or what also happens with probably about I don't know maybe 10 to 20 percent of the time they bulge out and they think that they're pulling up so again I think for any
It's just education about your body, right? Education is power. And so going to see those pelvic floor therapists. They are very underutilized in our medical community. my gosh, they are the, can't do my job without them. Yeah.
Kim Vopni (21:23.395)
Yeah.
Kim Vopni (21:27.758)
Oh, 1000 % Yeah. Yeah, we were on the same page there. Totally agree. Totally agree. Okay. And then from a recovery perspective afterwards, and this is where I'm going to circle back to that first question that I asked you about sexual medicine, two things. When would we think about? When do you recommend people would start their pelvic floor muscle exercise, or kegels or whatever you want to call them postpartum. So I'll just plant that seed there.
Aleece Fosnight (21:55.352)
Mm-hmm. Yep, yep, mm-hmm.
Kim Vopni (21:58.368)
And then what do you see in terms of incontinence interfering with postpartum incontinence interfering with return to sex postpartum?
Aleece Fosnight (22:08.536)
Yep, totally. engaging your core and pelvic floor muscles day one. I think that there's little...
Kim Vopni (22:14.368)
Hallelujah! Thank you for saying that. I know! Yeah.
Aleece Fosnight (22:17.7)
What a concept, right? Yeah, day one, why not? Right? It is not going to hurt anything. You got to wake up those muscles. You got to wake up those nerves. You got to get that mind, body back into play. And I realized like a postpartum timeframe, it's a lot. It's exhausting and there's all of these emotions going on and you have this little human being that, you know, is you're responsible for and everything else. encouraging women to again, as a self care thing, start day one. There are so many little things that you can do.
And it doesn't have to be weight bearing. doesn't have to be huge in terms of like do all these squats or else laying down and sitting. You can engage your core just as usually is like standing everything else. So it's just that progressive exercise that you can do. So yeah, so day one is definitely what I would recommend. And then in terms of right, the incontinence piece of it, we know that gosh, even the whole postpartum, it's a year, right? You know, it isn't just the six weeks before you go back to your
you know, OB and get the like sign off, especially for sex and penetration. So it's actually my one thing too, is I always tell people just because your OB gave you the go ahead for sexual penetration, if that's the type of sex that you're engaging in, doesn't mean that you have to. You have to be ready for it. So if that's at six weeks, cool. If that's at six months, that's fine, right? You are in charge and nobody should be pressuring you to do that. And so, but right, 85 % of women
women have incontinence postpartum throughout that first year of after they had a baby. And so the concern of leaking during sex is on that high list of why actually quite a few women don't want to engage in penetrative sex postpartum. And so with that piece of it, I think it's your comfort level of having that conversation with your partner. think communication is so key.
and into what's going on is going to make them a better parent, a better partner, a better person in this world when they have a better understanding of what's happening to your body during that process. And so as embarrassing a taboo it can be, break that taboo, break that stigma and have that conversation. We all pee, like we all poop. We all are having some sort of sexual activity, whatever that looks like for everybody. And so normalizing that
Kim Vopni (24:39.906)
Yeah. Yeah.
Aleece Fosnight (24:47.27)
conversation and that might be something that talk to your health care provider maybe first and bring up that concern. It's hysterical the research that's out there. The majority of health care providers won't bring up something because I think that their patient will bring it up and then the patient thinks that if it's important their provider will bring it up. So we're like we're at a stalemate and it's like okay somebody needs to have the conversation and really I actually do think that that is on the medical provider but I encourage a lot of my patients to have that conversation and even if you don't think
Kim Vopni (25:06.499)
Yeah.
Yeah.
Aleece Fosnight (25:17.19)
that your provider can tackle that conversation with you, ask for a referral and say, well, who can I talk to then? If this isn't your area of specialty, don't just let that conversation stop at that point. And there's lots of groups that are out there now, right? And so asking about, you know, postpartum groups, mom's groups, parent groups, things like that can also be really helpful. And a lot of times they'll bring in speakers and to have somebody to actually talk about these concerns as well.
Kim Vopni (25:45.134)
Yeah, I've also heard that people don't bring it up with their care provider for fear of embarrassing the care provider. Right. And so it's not so much even that they feel embarrassed, which they probably do a little bit, but it's, it's also not wanting to embarrass the care provider, which is, yeah, so we things need to things need to shift with regards to that and our, the system I'm in Canada, you're in the United States, but we have these, these
Aleece Fosnight (25:53.109)
gosh, yeah. Mm-hmm. Yeah.
Aleece Fosnight (25:58.518)
Kim Vopni (26:10.892)
I call sick care systems, not health care systems that are not set up really to have those in depth conversations and evaluations as it pertains to pelvic health or any really any aspect of health. just, it's like quick, very surface level, let's rule out life threatening and then here's a prescription or a referral to a specialist and we don't really have time for those explorative conversations. Yeah.
Aleece Fosnight (26:21.476)
Correct.
Aleece Fosnight (26:32.482)
Yep, yep, you're exactly, you're exactly right. Sure.
Kim Vopni (26:35.042)
What about prolapse? know we're kind of we were going to be focusing on incontinence, but prolapse is also another piece which can also contribute to sensations of needing to go to the bathroom more frequently or more urgently. How common do you feel? Do you see that in your practice?
Aleece Fosnight (26:50.988)
Yeah, gotcha. So, prolapse, do you want to, like, postpartum prolapse? Or are you talking just in general? Or... Sure.
Kim Vopni (26:57.614)
Well, both, guess. So we're on the topic of postpartum. But I remember seeing a study, and it highlighted, and this was vaginal and cesarean births. And the statistic in this study was 83 % of women at six weeks postpartum have some degree of prolapse. 50 % of the 83 have a stage two or greater, which I know prolapse is common. But the fact that nobody talks about it, nobody screens for it, and we have that.
that is a lot of people, right, that are affected. so is that in line with what you would see?
Aleece Fosnight (27:33.515)
Very much so, yes. So, and that's why I was asking, because like I said, it's super common for us to see this at six weeks. And then even at six months, a lot of times too, there still can be a lot of that extra pressure that's in there, especially depending on what that individual had to do for their maternity leave. If they only had six weeks, right, we have to think about too that we don't get the luxury of having, you know, three to six months potentially for our bodies to be at home.
to recover and depending on what you're doing for your job. If you're standing a lot, right, that's a lot of pressure on your pelvic floor and again why it's really important to seek those pelvic floor therapists because they can help with the alignment, right. Most people actually don't stand like they're supposed to and a lot of us tuck our pelvises and that's going to lead actually that pelvic outlet more open to gravity than if we're opening it up and almost kind of pushing our, you know, glutes out and so again just those little things can be really important.
But with prolapse, I think we are very quick to do surgery, right? Or to brush it off to say, well, it's not horrible, so you should be okay. Just modify your activities or something like that. But I don't think what we talk a lot about is pessaries and pessary use, which I think are fantastic. think like, pessaries are a great alternative to at least help give some support postpartum, Especially as you're starting to regain that strength in your pelvis.
And it's alleviating a lot of that extra pressure so that you're not having that pull and pull and pull downward again, like with that gravity kind of piece of it. And again, most of the time, you know, you'll talk to your OB-GYNs if you're going to have more kiddos down the road, they're obviously not going to want to do it. But it's really sad. I don't see actually a lot of OBs offering pessaries. And then again, I think it's the awareness. You know, when you go in for your check, it's six weeks or whatever else you're laying down. Most times that with that you have like a grade
want a grade two prolapse, you're not going to see it laying down. You have to stand them up. And so if you are feeling pressure as a patient, ask your provider, say, hey, can I stand up and you check me because I don't feel it so much when I'm laying down and I want you to be able to feel it when I'm standing up. So I think that that's also a big difference is we, don't, we don't examine women standing up a lot of times to actually feel where that prolapse may be coming from. And you can have uterine prolapse and you can have vaginal prolapse, can have
Kim Vopni (29:58.958)
Yeah. I was ha- Yeah.
Aleece Fosnight (30:03.094)
prolapse right there's all different ones are happening. The biggest thing too with prolapse is avoiding constipation. No matter what kind of prolapse you have anything that's going to put additional pelvic pressure in there. So make sure you're getting plenty of fiber moving your body and lots of water.
Kim Vopni (30:17.57)
Yeah, yeah, I was having a conversation with my friend and also my naturopath. She does sexual medicine as well. And she's been on the podcast, Dr. Jordan Dutton, and we were having a conversation about prophylactic use of pessaries. She's currently well, she's had she's had two babies. And we were talking about, you know, during pregnancy, in the early now, early postpartum is a little
especially in a vaginal birth, you don't necessarily want to be putting too much in there. But I think about, I had erectocele repair four years ago, and my surgeon used packing in the vagina afterwards, which again, we don't want to use that postpartum, need we need things to be flowing through. But there was an element of that where I was looking at that saying it's sort of prophylactic protection. And so I haven't really done a deep dive in this or really talked a lot, but I'm just kind of like,
Aleece Fosnight (30:58.297)
Yep.
Kim Vopni (31:14.2)
dabbling and asking people, sort of feel like there could be some prophylactic use of pessaries and, you know, for early stage prolapse management, like, let's give extra support and doesn't have to be postpartum. It could be somebody who is never even given birth before who has prolapse and potentially, you know, helping reduce that progression that I was looking at a study that it's, you know, it doesn't it doesn't always get worse. It can.
Aleece Fosnight (31:15.502)
Mm-hmm.
Kim Vopni (31:44.033)
And certainly as we get closer to menopause and when we face all the other challenges of aging, then it can happen, but it's not a guarantee for every single person, which I thought was interesting. But anyway, I just kind of was, I guess, curious on your thoughts of that.
Aleece Fosnight (31:59.013)
Yeah, no, think prophylactic is a great option, right? The lens that we should use for everything is a preventative lens. So what are the steps that we can do to help prevent something from happening? And it seems like a very logical way to do that. I also am a big proponent of, again, I'm not a fan of how we deliver, how we labor our women. I mean...
the stories of women pushing for two, three, four hours, even seven. Like I'm like, are y'all nuts? Like what is happening, right? Like this is just ridiculous. And you think about all of that pushing and pushing and pushing and what that's doing to that pelvic floor and all of those pelvic organs, it's sad and disappointing. So yeah, and that we know better and we should do better. Yeah.
Kim Vopni (32:41.762)
Yeah, yeah.
Kim Vopni (32:45.678)
Yeah, yeah, 100 % agree. So the and I think kind of wrapping up that part of the conversation, incontinence is one thing that can hold people back from returning to sexual activity as can prolapse. And yeah, and I see I see prolapse even maybe being halting people in their tracks a little bit more than than incontinence does. And a lot of like people have heard of incontinence, they're kind of maybe expecting it. Again, no conversation around
prolapse and they interpret this as, I have cancer? Is that a tumor? This bulge that they see or feel is really alarming to people. And yeah, so I feel like that.
Aleece Fosnight (33:23.896)
Mm-hmm.
Yeah, and having that intimate moment with your partner, mean, that can be really scary and feel fearful of like, well, what's my partner gonna think? Or I think that there's a lot of fear around, again, what their partner's gonna think anyways of the vagina. know, but is it, right, right, right, right. But again, that all goes back to, again, these are mostly penis owners, right? So it goes back to the vagina being there for men's pleasure and not it being there for women's, so.
Kim Vopni (33:29.006)
Mm-hmm.
Kim Vopni (33:41.718)
Right, is it different? Is it loose? it, yeah.
Kim Vopni (33:51.554)
Yes.
Yes, yeah, yeah, I agree. Coming back now then to look at those, those different categories of incontinence. And I also want to, I also want to talk about anal incontinence as well, which is less common, but but something that can happen as well. So gas or stool leaking out. So I kind of all of those, those categories, starting with stress urinary incontinence, what are your what strategies do you recommend for whether this is postpartum or
Aleece Fosnight (34:06.701)
Yeah.
Kim Vopni (34:23.554)
I I'm going to assume, but I shouldn't assume that your answer will be the same whether they're postpartum or somebody else dealing with stress incontinence. how, what are your recommendations for somebody to overcome stress urinary incontinence?
Aleece Fosnight (34:35.554)
Yep, absolutely. So my my go-to, like I said, is pelvic floor physical therapist is going to be the first one. Right. I like to say as conservative as possible, but also going, OK, well, why is this happening? What's the mechanism of action of how this happened? Is it because you're six weeks postpartum? Is it because you just had an abdominal surgery? Is it because you have been sedentary because you're now working from home? Right. And those muscles have atrophied or weakened. And so it's just like, where is this coming from?
from so that we can find the root of the cause of it and then really appropriately then put you in the hands of a pelvic floor therapist is what's really, really helpful. So yeah, that's gonna be my go-to for that. You know, we talk a lot about decreasing a lot of the abdominal pressure. I'm a health at every size provider, so I don't weigh my patients. I'm not a weight focused when somebody comes in with a concern, but we do know that when there is a decrease of the inter-abdominal pressure
secondary to a weight component can be helpful. I think there is a study out there that if you lost like 10 % of your body weight that that reduces your stress urinary incontinence by over 50%. So thinking about that, but obviously doing it in a very health conscious way and not starving yourself or being, you know, know, counting calories and whatever else. There's other ways to do that. So, so those would be kind of the things that I would think about for the, least the stress urinary incontinence for the overactive bladder. A lot of it is pelvic floor, right? It's the same thing.
When we start getting into that it is a signaling from the nerves, that may be something else that we have to do. Maybe a lotus medication, maybe some other neurogenic pathways and modalities like nerve stimulation can be really helpful for those individuals. I do like to stay with a pretty conservative approach to it. Although I have a urology background as a urology PA and I've done lots of first assist with surgeries, I try to make that my last option for those people. As a sexual medicine provider too, I
about all of these slings or meshes that we're putting into our female patients and because where we're putting that is on the top part of the vaginal wall which is where we see a lot of those really rich nerve bundles from the periorethral glands which is the skeins glands which are homologous to like a prostate tissue but in our vulva owners and that can be a really source of pleasure for a lot of individuals and so I want to just always be be mindful of that. You know we had talked about pessaries some of those pessaries have knobs right and so that
Aleece Fosnight (37:05.094)
knob that'll be in kind of the front area to help support the urethra is another great way to and meeting your patients where they're at, right? Some people only leak when they're running. Okay. So what are the things that we can do to help with that? And that's another thing about pelvic floor physical therapists too, is that they have this whole background on just physical therapy in general. So, all right, how are you running? Right? Okay. Let's look at the mechanism of that piece of it and see if we can fix anything or change something that can actually help decrease some of that strain on your pelvic floor while
you're running. Weightlifting may be another thing too that people are just experiencing during that. So again, meeting that patient where they're at. Now, like I said, in terms of urgent comments or overactive bladders, again, maybe some medications would be something you could do if it's related to again, pelvic floor tightness, because that's causing that bladder to to want to go more frequently. Again, your pelvic floor therapist are going to be what you're going to do. And then again, it's a mixed, you know, kind of a bag to with the majority of the incontinence
So it's being both stress and urge. So pelvic floor therapy is gonna just always be my go-to. I think that's always gonna be my answer. Like I don't ever like ever see like anything ever be, it's gonna be pelvic floor PT and, know, like I think there's just you, that's just an automatic. And my poor pelvic floor therapist in my area are like, they're gonna have to hire more people because I send at least, you know, two and three people, I feel like almost every day to a pelvic floor therapist.
Kim Vopni (38:11.394)
Yeah. Yeah, I know.
Kim Vopni (38:19.126)
Yes. Yes.
Kim Vopni (38:28.002)
Yeah.
Kim Vopni (38:31.758)
Yep. Yeah. Yeah, we're the same. literally scream from the rooftops and that's always my number one thing. Go see a pelvic floor physical therapist. I do. I think as you said, they're the most underused women's health resource that we have and I literally, it can change lives. It could save our sick care system, kajillions of dollars. It can save relationships. just, is so, the therapy they provide is so powerful. So thank you to all pelvic floor PT's who are listening and yeah. So.
Aleece Fosnight (38:40.536)
Mm-hmm.
Aleece Fosnight (38:58.242)
Yes, shout out.
Kim Vopni (39:01.376)
What would be different, if anything, if somebody was struggling with anal incontinence compared to urinary incontinence?
Aleece Fosnight (39:06.948)
you
So it goes back to what's the mechanism, like where is this coming from? And especially if they are postpartum and there was any trauma to that posterior vaginal wall, right where the rectum is. So when you start getting into even second degree, but mostly third and fourth degree, know, tears that are happening to that area, it's depending on how that was repaired and how much of that anal sphincter was involved in that. So this is where pelvic floor therapy is definitely gonna be there. But I do find that actually a lot of people with gas
Kim Vopni (39:34.584)
Chalk her.
Aleece Fosnight (39:38.883)
and stool leakage that happens is they're constipated. So it seems very counterintuitive to be like, wait, I have to have more fiber or you want me to drink more water? I think that that's gonna be the biggest thing. And then making sure that when they're toileting and emptying out their bowels, are they doing it appropriately? So who teaches you how to poop, right? Like that's the thing to think about of you don't wanna strain, you don't wanna push, you wanna relax, right? Which is very, again, counterintuitive of what
I think people think about, right? You want to belly breathe, push your belly out, let that diaphragm go, open up those pelvic floor muscles. And so, you know, it's learning how to evacuate your bowels, I think is also the big thing that can happen. And then obviously seeing colorectal, if there is something really concerning there too. Again, nerves could be a component and there's some great neuromodulators systems that are out there too that can really help to curb that incontinence for you as well.
Kim Vopni (40:37.454)
Yeah, yeah. Thank you. Is there anything that we haven't touched on that you wanted to address?
Aleece Fosnight (40:45.24)
I don't think so. think again, this is a, you know, it's not a one modality, right? That is going to actually be there. I really take this from a multidisciplinary approach to that. You need everybody. Don't forget about your mental health therapists, right? I can't do my job without them also because this is a huge burden that you're taking on. So I think that that's the other broken system in our communities is again, the amount of pressure and responsibilities that are continually put on our female
folks in our country. And so mental health, think, is another great one too. There actually is quite a few postpartum or pregnancy specialists that are in the mental health field as well. Usually here in the States, we have psychology today where you could go search for somebody and it'll have on there what their specialties are and you can search for those specifically, which is really nice. And then the other thing is just insurance, right? You know, that's a huge barrier for a lot of people and the cost for this.
A of my pelvic floor therapy colleagues are going to cash based and that's really a limiting factor for so many individuals where from a service line that should be available to everybody, it's maybe difficult. And then the accessibility, cause you may not have a pelvic PT in your backyard that you can go to and just drive 20 minutes down the street. You may have to drive an hour. I have lots of, I know too many people that kind of live in a pelvic floor therapy desert. And so they have to travel an hour to go see that. And if you're seeing those folks once,
or even twice a week, that's a lot. It's a lot of travel. We do, I think, have some really good resources that are online. Origin is an online pelvic floor therapy option and I think that they do take insurance so you could always look at that too. I'm a big fan of hands-on though, like being able to actually, you know, evaluate that person and see what their hips and their pelvis is doing is important, but if that is your only other option it's better than nothing.
Kim Vopni (42:30.978)
Yeah.
Kim Vopni (42:40.044)
Yeah, yeah, yeah, I'm a big supporter exactly as you're talking about is happy. We need that we need a healthcare village or team. And it relieves the burden off just one doctor to have to know everything off the system itself. But also, we get multiple opinions and multiple. We appreciate more that there is it's not just I need to fix this muscle and then everything's gonna it's I was just interviewed somebody else this morning.
His name is Anthony, does function first as his and he's a movement professional biomechanics takes very much a biopsychosocial approach. And we are talking about that. And that's something that it's a I guess I've heard it talked about in the field of pelvic health probably for the last maybe eight or so years, but it's not necessarily something that the consumer would necessarily think about or talk about. And again, simply, we've just never been taught about it, right. But
Aleece Fosnight (43:34.998)
Mm-hmm.
Kim Vopni (43:36.556)
Yeah, love everything you're sharing. Thank you.
Aleece Fosnight (43:38.018)
Yeah, and imagine if we like actually talked about this in school and my goodness. Yeah, I know I right now I have three kiddos and again, they're all vulva owners. So we are very open about anatomy, you know, in a household. And so I think starting early and talking about it often is just so so important and having the awareness of it. So
Kim Vopni (43:41.878)
Yes! Yeah.
Kim Vopni (43:57.006)
Yeah. Yeah, 1000%. Totally, totally agree. Where can people learn more about you and find you in your work?
Aleece Fosnight (44:04.598)
Yeah, gotcha. So, the Fosnight Center for Sexual Health is my private practice in Asheville, North Carolina. You can go to thefosnightcenter.com to find out more about me. You can follow us on Instagram at Fosnight Center or myself at SexmedPA and then check out our Aeroflow Urology as well. There's going to be a lot of resources from an insurance perspective to if you are dealing with incontinence and you need some incontinence supplies to tide you over or to you can get to those pelvic floor. Your insurance, a lot of times we'll cover that, but people don't know it.
So reaching out to Aeroflow Urology, which is just aeroflowurology.com, you'll be able to find some resources and their customer service is amazing. If they can't figure it out, they're going to find it out for you and call you back. definitely reach out and yes. So again, thank you so much for having me too, Kim.
Kim Vopni (44:46.84)
Awesome.
Kim Vopni (44:51.458)
Yeah, thanks so much. I appreciate it.
