Kim (00:01.702)
Hello, Dr. Efraim. Thank you very much for joining me today. I am really excited to share the topic of, in particular, colpal cliasis with my audience. This is something that I do get asked about quite frequently. But before we dive into that, I would love for people to learn a little bit more about you and what brought you to becoming a physician and particularly focusing on pelvic and reconstructive surgery.
Dr. Sonya Ephraim (00:28.75)
Sure. Well, my original training was as a general OB-GYN and I knew from a very young age that I wanted to go into medicine. I was always fascinated, especially with women, our reproductive system. I had toys as a child that dealt with the female reproductive system and being able to see the anatomy in women and just loved it. And then...
It never went away, right? As I got older, I got into medical school and did my rotations and honestly tried to pick something else because I was afraid of the lifestyle and it just never stuck. You know, I felt at home when I was taking care of women. I connected with them easily. They shared things with me easily. So I love it. And as a general OBGYN, I did that for about four or five years. I graduated from Rush University Medical Center in Chicago.
Kim (01:02.043)
I'm gonna go.
Dr. Sonya Ephraim (01:22.362)
and then decided that I really enjoyed reconstructive surgery. So after residency, you can go onto fellowship to subspecialize. And the patient population that I was taking care of was aging. And so I was seeing a lot of patients with incontinence and prolapse and vaginal atrophy and all those problems that happen when we're done having children, right?
And I had good training and residency so I could take care of some of it, but all the big cases I had to send back to my mentors and I'd be on the phone like, hey, I got this case I'm going to send to you and gentle prodding. They're like, you know, you should really go back to fellowship. So eventually the stars aligned just right and I realized how much I really love surgery. It was very challenging and very rewarding for myself and for my patients. That improvement in quality of life that you give back someone.
I got more hugs and kisses and cookies and plants from patients for doing that than I even did for delivering their babies, you know. So it was just a natural transition and it's the perfect fit. I absolutely love what I do.
Kim (02:33.578)
Amazing, I love that. And you now have a clinic dedicated to women's health and you've mentioned a few of the top ones that obviously I speak a lot about, which is incontinence and organ prolapse. So are those the most common issues that people are coming to seek treatment for?
Dr. Sonya Ephraim (02:53.37)
Absolutely. That's my bread and butter is incontinence and prolapse, right? So a lot of women, they don't realize that they're not alone and that this is a huge problem that so many of us are dealing with. It's just that we don't really talk to each other about it. And so you feel alone. You feel like something's wrong with you. But to reassure them, I have an entire career based on this, right? So it must be a very common issue because of that.
Kim (02:55.846)
Hehehe
Kim (03:03.055)
Right.
Dr. Sonya Ephraim (03:22.678)
and it's just nice when they come in and sometimes women are very, they're nervous, you know, it's the unknown, they don't know what to expect. It's nice to be able to reassure them that there's a whole specialty dedicated to them and that I do have lots of options from conservative, you know, pessary use all the way up to major reconstructive surgeries or, you know, like we'll discuss later today.
obliterative procedures where maybe they don't need that aspect of life anymore and it really is the best surgical option for them.
Kim (03:57.83)
Mm-hmm, mm-hmm. Yeah, and I do wanna touch on those two very distinct differences. But before we go there, so I do cover, I know we wanna cover that obliterative surgery particularly in this, but I'd love to ask just a couple of questions about incontinence and other types of prolapse surgeries as well. So from an incontinence perspective, mainly surgery is for stress urinary incontinence, not so much.
Dr. Sonya Ephraim (04:03.168)
I'm here.
Dr. Sonya Ephraim (04:15.477)
Love you.
Kim (04:25.994)
urgency or urge incontinence. Do you think that's a fair statement?
Dr. Sonya Ephraim (04:29.166)
Um, well, there are some surgical procedures that are available for overactive bladder. Um, not traditional what we think of when we think of major surgery, but, uh, women who have urgency, frequency, can't get to the toilet fast enough, leaking as they're getting their pants down. There's procedures such as InterStem, which is neuromodulation. The way I explain it to my patients is like putting a pacemaker on your bladder.
to stop all that frequency and urgency and give you more control over the rhythm of your voids, so that you're not just going all over the place. It's more predictable and controllable. And so that is one surgery that's available for incontinence for overactive bladder. But yes, the majority of the surgery I do for incontinence is for stress urinary incontinence to give back support to the urethra. So...
Everything becomes lax and loose after we've had kids, we get old, maybe we were smokers. And so the coughing, sneezing, laughing, jumping up and down, you just can't hold the urine back. Often a surgical procedure is a really, really great option for women because it's minimally invasive and recovery is great. In the right hands, it's a really wonderful procedure.
Kim (05:42.638)
And those would be the sling procedures more so, is that correct?
Dr. Sonya Ephraim (05:45.934)
Correct, a pupil vaginal sling. It's like a little tiny piece of tape that you put underneath the urethra to give back the support that your own connective tissue isn't giving anymore.
Kim (05:55.022)
Right, right. Can you talk a little bit about the overactive bladder procedure, the pacemaker? Can you name it again and tell us how that's actually performed?
Dr. Sonya Ephraim (06:00.892)
Mm-hmm.
Dr. Sonya Ephraim (06:04.162)
So Interstim is a procedure that's, well it's called neuromodulation. There's a couple companies that have a device that you can use. The one that I use most often is called Interstim by Medtronic and it involves, the nice thing about it is that you can do a test in the office with a little temporary device called a PNE. You lay on a, in my office I lay you on a massage table on your tummy.
and I place a very fine lead, it's about thickness of a strand of hair, I just make a poke mark with a needle and pass it down. It lays next to the sacral nerves that control the bladder and the pelvis. This is done in the office with just a little local numbing, completely comfortable, and once we get the device in place, we kind of tape everything down, and you wear a teeny tiny external fanny pack with a battery on it for about a week.
and you get to go home and try it out. And if you try it out and you say, oh my gosh, this is the best thing since sliced bread, my bladder symptoms are so much better. I'm not running to the bathroom, I'm not wetting myself. Then we say, yay, and we move forward with the implant of the actual device, which at that point we go to the operating room, you're still under sedation, it's not like under general anesthesia, you're on your tummy again, I put the permanent lead in, and then there's a little tiny battery.
that goes under the skin in your buttocks. So you can feel it if you touch it, but it's not anything that's gonna distract you or hurt you or be noticeable to anyone else. And that battery is what controls things. And then you get a little, I was gonna say palm pilot, but that ages me, right? So you get like a little cell phone thing.
Kim (07:47.558)
I haven't heard that for a long time.
Dr. Sonya Ephraim (07:53.51)
And the cell phone, it looks like a cell phone and it's got all the controls so you can turn the device up and down and control, there's different programs that you can use. And that helps so that you have control over the urgency, the frequency, you don't wet so much. And we consider the test successful if you have an improvement in your symptoms of at least 50%. So that's an important thing for women to know about overactive bladder. And they're like, well, is it going to work? Is it going to work?
I can tell you what research says, right? In all of our studies, the standard is, did this treatment, did this intervention improve the patient's symptoms by at least 50%? So if you went to the bathroom 20 times a day, now are you going 10? That's a success. If you went through eight pads a day, now are you going through four? That's a success, according to research. Now, is that good enough for you and your quality of life?
That's the other aspect that we have to talk about. So sometimes we use multiple therapies. I may do an interstem and bladder botox or an interstem and an oral medication to try to get past that 50% mark and get it even better. Mm-hmm.
Kim (09:04.93)
Got it. And there was just a quick lag when you were talking about when you're performing the surgical procedure, there's not a general anesthetic, but can you just describe quickly again where it's actually placed, where's the incision and what actually are you putting in?
Dr. Sonya Ephraim (09:22.034)
Mm-hmm, so I wish I had my model with me, but it's on your butt. So we pick a side, usually the side. If you're a side sleeper, I pick the side that you don't sleep on. And then if you imagine below where your belt sits, but above where your cheeks are sitting on a chair so that it's not interfering with anything. So somewhere between below the belt and above the flat of your butt when you're sitting on a chair.
Kim (09:31.735)
Okay.
Kim (09:41.541)
Okay.
Dr. Sonya Ephraim (09:50.066)
I find a little tiny pocket about two inches long, and I make an incision and make a little pocket with my finger and I put the battery in there and sew it up. And those batteries now can last 10 to 15 years. And so we check them every now and then. And if you do need a battery replacement before I retire, then it's a very simple procedure of going and opening that old incision, kinda like you're a toy. I pop the battery out.
Kim (10:19.474)
Hahaha
Dr. Sonya Ephraim (10:20.01)
pop a new one in and then you're good to go.
Kim (10:23.146)
And then, sorry if I missed this, but where does the, so is it, the battery is influencing the lead. Where is the lead placed?
Dr. Sonya Ephraim (10:30.646)
Correct. The lead, so the battery sits in the pocket, the lead is tunneled under the skin towards your crack, towards the midline, and then it goes through the S3 foramen. So you know, your tailbone, one just so for our laypeople who don't know exactly, but one, two, S3 is where the nerves that control the pelvic floor and the bladder and all of that, those nerves lay there.
Kim (10:43.526)
to.
Dr. Sonya Ephraim (10:55.598)
So it just lays very gently next to those nerves so that when we turn the stimulation up or down, it can help filter out all the bad signals that are making you go so frequently and give you more control. And it works really, really well for overactive bladder. It actually works even better for fecal incontinence. So sometimes women have to both problems and women who come to see me who have both, I definitely recommend that they trial that procedure.
Kim (11:13.347)
Oh, wow.
Kim (11:22.382)
And then you talked about, I wanna come back to the fecal incontinence, but I also want before we jump there to talk about bladder Botox that you mentioned as potentially a complimentary intervention. So how is, where is the Botox injected? How long does that last? And we think of Botox on the face where it's relaxing muscles. So is it essentially coming in and relaxing the bladder?
Dr. Sonya Ephraim (11:34.179)
Sure.
Dr. Sonya Ephraim (11:47.778)
Mm-hmm. Yeah, so bladder Botox is one of my favorite things to do because it works so well. And honestly, if insurance companies would let me skip oral medications and go straight to Botox, I would because it's so hard to get people to take those medications and a lot of them have side effects that people don't like. The Botox is a simple in-office procedure. I just have a small cystoscope that I put in through the urethra. Painless. I know it sounds awful having something stuck in your urethra, but it's not.
We put a numbing gel in there and let you sit and so you barely know what I'm doing. We put the camera in and then I inject the Botox into the bladder, the bladder wall. And it takes, you know, just like Botox anywhere else on the body, it doesn't work instantaneously. It does take maybe two weeks for it to kick in, but once it kicks in, most women will get between four to six months of relief.
from their urgency, frequency, bladder accidents. And so they're coming in two, three times a year for a five minute procedure to get their injection. And then they get to have a much better quality of life. And it does act by kind of relaxing the bladder wall. It stops the neurotransmitters from crossing and causing that bladder to spasm and contract and gives you just much better control.
Kim (13:12.422)
Got it, thank you. So coming back to the fecal incontinence, why do you feel like the interstim is so, interstim, did I say that correctly? Yeah, why do you feel like that is so helpful for fecal incontinence?
Dr. Sonya Ephraim (13:13.431)
Mm-hmm.
Dr. Sonya Ephraim (13:21.201)
Correct.
Dr. Sonya Ephraim (13:28.174)
Well, in my clinical experience and research shows that it works really, really effectively for women. You know, fecal incontinence is something that gets worse as we get older, and oftentimes it's hard to figure out why they're having the fecal incontinence. And so interstim is something that we know works, but there's not a lot of hard data as to why it works. We just know it works. And so...
It is also people who have like urgency for bowel movements. It works very well for them. And, you know, of all the incontinence, urinary incontinence is terrible. Fecal incontinence is at a whole nother level. Talk about taking away your dignity and your lifestyle and everything. Women are distraught when they come and they have fecal incontinence. And so it's very, very gratifying to be able to-
fix that for them and give back that quality of life. So, and they, like I said, they often come hand in hand, the urinary and the fecal together. So it's just a phenomenal treatment. And unfortunately with fecal incontinence, we don't have a lot of options that actually work very well. So the InterStim is great.
Kim (14:41.274)
Amazing. And then when people are coming to see you, sometimes they may have incontinence, maybe urinary and or fecal, and they're also dealing with prolapse. And so reconstructive surgery is one option that we can chat about first, where they may have a bladder repair, a hysterectomy, a uterine suspension. There's all sorts of different options there. And the...
Dr. Sonya Ephraim (14:53.687)
Right.
Kim (15:08.526)
The challenge, the great thing, but the challenge about pelvic surgery is there are so many options. So you really have to come in, it's a very personalized approach that you would take with that person. So how would you evaluate? What are some of the things you would look at when you're helping a person decide on maybe if they should suspend the uterus or have a hysterectomy? Should they repair a small cysticel at the same time? How do you go through the different options with them?
Dr. Sonya Ephraim (15:36.582)
So, you know, I start with my history and physical, gather all my data so I know what I'm working with, right? And sometimes you get something very mild, like a patient didn't even realize she had a prolapse, but maybe she went to her annual exam and her doctor told her she had one. She's completely asymptomatic. And at that point I say, if it's not bothering you, I'm not bothering it. So let's just leave it alone. If it ever becomes symptomatic, let me know.
Kim (15:58.946)
Yep.
Dr. Sonya Ephraim (16:04.086)
And then you get the extreme cases where maybe the there's a complete vaginal inversion everything is out So once I have the physical exam and know what kind of defect I'm dealing with Then I have the same conversation with everyone and I asked them. What are their goals? Okay, how old are you how physically active are you how sexually active are you? Do you have a job that you can afford to take time off and recover?
Do you have a job that requires heavy lifting? Are you able to modify that? So there's a lot of questions that go into it for me to decide, okay, these are the options that I think are best for you. But I always, always start, oh, you can do nothing. You can use a pessary or you can have surgery. And surgery comes in two flavors, reconstructive or obliterative. And then I describe what reconstruction means and what obliteration means and tell them obliterative procedures are
phenomenal, lowest failure rate of any surgery I do. However, you have to know that vaginal penetration is no longer important to you. Because once I take it away, I can't give it back. So if there's even the slightest chance that Mr. or Ms. Wonderful may come into your life and you may wanna have vaginal penetration, then we shouldn't do that. But if you know that that's no longer important to you.
and you'd be happy just holding hands if somebody came along, because there's other ways for pleasure, right? Besides penetration. So I have that very delicate conversation too. Then maybe this is the right option. Maybe you have comorbidities that don't make you a very good surgical candidate. And this is the best way. Maybe you've been using a pessary for years and you're tired of it and the pessary visits are strenuous and stressful and you hate it. And maybe it's like, okay, maybe it's time to move on to do this obliterative procedure.
and see if we can't just improve your quality of life. That's really everything that I do is about.
Kim (18:01.858)
Right. So how would you describe the difference between reconstructive and obliterative?
Dr. Sonya Ephraim (18:08.302)
So a reconstructive surgery is for a woman who still wants to have access to her vagina. She wants to be able to have penetration by herself or with a friend. She wants to be able to utilize that. She's not ready to give that up. It basically puts everything back where it belongs and restores normal anatomy. And so you'll look at the outside, you'll look at the inside, someone can put a speculum in, a finger, a digit, whatever. And
they would see a normal vaginal canal. It can be done leaving the uterus in place or it can be done in combination with a hysterectomy. And that's a whole nother conversation too about the risks and benefits of taking the uterus out. I find very, very often a hysterectomy is not necessary. And really what it does is makes the surgery longer, gives more risk, more morbidity. So if I don't have to take a uterus out, I leave that thing right where it is, you know.
Kim (19:05.51)
Mm-hmm.
Dr. Sonya Ephraim (19:06.691)
because there's lots of research that shows that women get great long-term results with the uterus in place.
Kim (19:13.038)
Yep, yeah, I'm happy to hear that. I know that it's one of the more common procedures. So many people are sort of just said, well, I'm in there, I might as well take it out. You don't need it anymore. And I feel like that's not necessarily always the best option.
Dr. Sonya Ephraim (19:21.856)
Oh, yeah.
Dr. Sonya Ephraim (19:26.154)
No, no, I think, you know, surgery is, it's a big thing, right? And I love operating, but I think I've had such great results throughout my career because I'm conservative. I don't mess with something if it's not bothering me, right? And so if that uterus is fine just where it is, we're going to leave it alone. Because why would I increase your risk, make your surgery longer, worse risk of bleeding, infection, things like that, if I don't have to?
Kim (19:40.87)
Mm-hmm. Right, right.
Kim (19:54.702)
Right, right. Okay, and then obliterative means then there's no access to the vagina. So can you describe the, what does the term copal claisis mean and how is the surgery performed?
Dr. Sonya Ephraim (20:10.698)
I'm gonna ask you to repeat that, because you froze on me for a second.
Kim (20:14.014)
Oh, sorry, okay. So talking about the obliterative procedure, meaning as you described, there's no access to the vagina. So how is the surgery performed? Is the vagina taken out? Is it closed up? And are there different techniques to perform a colpal claisis? And also what does the term, I always am curious of how things are named, what does colpal claisis mean?
Dr. Sonya Ephraim (20:42.454)
So copalcaleasis is essentially a closing of the vaginal canal, the colpectomy, right? We're closing, that's the Latin root of it, is just the vaginal canal. So we're closing that. It can be done either with the uterus in place, or if a woman has already had a hysterectomy, we can still do a copalcaleasis, or if she wants a hysterectomy at that time, we can do the hysterectomy first and then do a copalcaleasis.
Essentially, it's a good procedure for women who have a very uniform defect where like the entire length of the vagina is falling down. It's very, very difficult if it's just like the ceiling or the anterior wall that's falling or it's just the floor. It has to kind of be the whole thing that's coming down in order to make it a good procedure. And then in those situations, I do most of my procedures under spinal anesthesia.
It's very in sedation, so it keeps our anesthesia risk low. Sometimes patients are afraid of general anesthesia. They don't wanna be put to sleep or a tube down their throat. So we can do the surgery without that. And then we take the vagina. The easiest way I can explain it is if you think of the vagina turned inside out like a grape, we peel the grape and then we sew it together. So another analogy I use is
Have you ever gone camping and you know those cups that you take camping that collapse flat so they're easy to pack and they telescope out? So basically I'm collapsing your cup. So that now when you, when I'm all done, when you look at the outside of the vagina, it still looks normal. Nobody would be able to tell if they looked at the outside. Your vulva still looks the same.
But if they tried to put a finger or a speculum or anything in, they'd get about an inch. And then they'd hit a wall. Right? It's like that cup that you collapsed. You can't push your finger in. But if I expanded the cup, it would extend back and I'd be able to put my hand in it. Right? So we just collapse everything down and then sew the skin closed. So again, looks normal on the outside. Nobody'd be able to tell. You just can't have vaginal exams or penetration anymore.
Dr. Sonya Ephraim (23:06.838)
And it's a great procedure. It's relatively quick. It's minimally invasive in that we really are not entering the abdominal pelvic cavity at all. So your risk of injury to other organs is minimal. And your blood loss is minimal. And the recovery afterwards, patients have minimal pain. It's really just a phenomenal procedure for patients who.
are not good surgical candidates or just know, hey, I'm done, I don't need a vagina anymore, and I just hate this prolapse, I don't ever wanna deal with it again, it's a great option for them.
Kim (23:46.062)
So you talked about how it's easier to do if there was a vaginal vault prolapse, which is more common after a hysterectomy and not as optimal if somebody had say a bladder prolapse or maybe let's say they had erectus seal. So why is that? What is making it
Dr. Sonya Ephraim (23:55.976)
Mm-hmm.
Dr. Sonya Ephraim (24:05.39)
Correct.
Kim (24:12.258)
Like what is it that makes the surgical outcome or the procedure better if it's not just the bulges? Does that make sense?
Dr. Sonya Ephraim (24:20.334)
So yeah, so pelvic anatomy, as you know, is probably one of the hardest parts of the body to comprehend because it's, you're thinking in this three-day space, right? But if you think about a vaginal vault prolapse or a prosedentia, it gives me one uniform thing to work with, right? I've got this bulge out and I can collapse it very uniformly. If you just have a bulge on the anterior wall.
and the posterior wall is way inside the vagina. It's very hard, there's nothing for me to reach in and sew it to, and I can't yank the vagina out, you know, to be able to sew it up. So it's just a matter of the mechanics of it, that it's, and if your posterior vaginal wall is in good position, I don't want to disturb it. I wanna leave it there, cause it's well supported. So in those situations, I'm just gonna address the area that has the defect. So the...
Kim (24:58.574)
Got it.
Dr. Sonya Ephraim (25:19.67)
the cobalt clases is better for people who have a large or uniform defect.
Kim (25:25.786)
Got it. So the intention is that they won't have the sensation of the bulging and the heaviness and needing to wear the pessary and that type of thing. So is it pretty much like, do people walk away, not walk away, but after they've had their recovery, are they symptom free for the most part?
Dr. Sonya Ephraim (25:36.046)
Correct.
Dr. Sonya Ephraim (25:44.83)
Yes, absolutely, it's a wonderful procedure. Like I said, the recovery is really great. They have minimal pain, minimal bleeding, they can urinate normally. I mean, it is very often times that I am doing an incontinence procedure at the same time, because if you've got a prosodentia or vaginal vault prolapse, most likely your urethra isn't well supported and we have to re-support that. But because we do that too, they're dry, they can go to the bathroom, they can empty completely, they feel fabulous afterwards.
And I've only seen one failure in my entire career. And it was a woman who had her surgery somewhere else. She got sent to my office because her doc wasn't quite sure how to handle it after the failure. And she had her surgery and then had severe bronchitis right after. So she never had a chance to heal. And it just popped right out. Because remember with the copal colitis, I'm not excising anything. I'm not removing the vagina.
I'm just kind of very neatly tucking it back into position and sewing the front, the entrance, the entroi is closed. So if you don't give it time to heal and you've got bronchitis or some other extreme valsalva force, you can bust through those stitches and it popped all the way back out. It was right back to where she started. But I've only ever seen that happen once. Most people take the time and heal and they do just fine.
Kim (27:12.074)
Yep. Can you describe the term, procedentia?
Dr. Sonya Ephraim (27:16.15)
So, prosedentia is a term that's used for a vaginal fold prolapse when the uterus is still in place. So you've got, your entire vagina has turned inside out. I describe to my patients, like, I'll point to their foot, I'll say, you see the toe of your sock? Like, this is the toe of your sock up here, this is the opening where you stick your foot, and your vagina has essentially turned inside out and now the toe is hanging out the other end.
So if there's no uterus, then it's a cuff and it's like the toe of the sock with the seam there. If there is a uterus, then the first thing I see is that little round pink donut, which is their cervix. Mm-hmm.
Kim (27:54.942)
it. Okay and from what we think of going back to reconstructive surgery restoring anatomy so to speak and in the obliterative procedure the what you're not making any excisions incisions so the bladder may still if I'm correct in visualizing this the bladder could still be not in the
Dr. Sonya Ephraim (28:05.334)
Mm-hmm.
Kim (28:24.874)
optimal anatomical position even after the copalcaleasis procedure, but they would still be symptom-free from that bulge. Is that accurate to say it that way?
Dr. Sonya Ephraim (28:38.554)
Yeah, so if you think with the bulge, the bladder is behind the vaginal wall hanging outside of the body. And so a lot of those symptoms become because like, oh, I can't empty all the way. Well, that's because your bladder is hanging down and you're fighting gravity trying to get the urine up and out and around and out the urethra and that you can't do. So in order to resolve the bladder symptoms, you don't necessarily have to get the bladder back into its perfect anatomical position.
You really just wanna get it back into position where abdominal forces are exerted on it uniformly, right? If we cough or we Valsalva, that force is exerted, or if the bladder contracts, that force is exerted uniformly, and it's not fighting gravity so that the urine can come out. It's also relieving any kink in the urethra that has happened because the bladder has dragged the urethra down.
So now your urethra is nice and straight, it's open, you can urinate, you can void, and you don't have this droopy balloon hanging where it's hard to get all the fluid out of it. It's back up elevated into the pelvis at least, so that it can empty completely. You can hang.
Kim (29:50.502)
Got it, amazing. And so you've mentioned that you can do this procedure at the same time as a hysterectomy. It could be done in somebody who still has uterus, somebody who doesn't, but if I'm making the proper assumption here, it couldn't be done in somebody who is still menstruating. Is that accurate?
Dr. Sonya Ephraim (30:12.13)
Correct, I wouldn't recommend it for someone who's still menstruating. In women who still have a uterus in place, we do even leave channels, so I won't close it 100%. I leave a little channel on each side, just in case she were to have discharge or post-menopausal bleeding, it would be able to come out and we'd recognize it, so that if we had to go back and do another surgery, like, okay, we need to evaluate this post-menopausal bleeding.
we can actually see that it's happening and not that it's stuck, because that can cause a lot of pain and discomfort if that's like a blocked up pipe, right? And your uterus is just getting full and full of blood.
Kim (30:54.086)
Right. And so knowing that and knowing that, and you can tell me in your experience, I think most of the people who are pursuing the obliterative option are postmenopause. And they may have had years of...
maybe atrophy, some people may even have like not a lot of room at the opening. Is that, would that come and be prohibitive for an obliterative procedure if they had really extreme atrophy?
Dr. Sonya Ephraim (31:27.046)
The atrophy is not such a concern, because I'm gonna be taking that skin off anyway. Like I said, I was peeling the grape. I'm peeling all the epithelium off of the vagina to be able to close it. If you think, like, if I tried to sew the vagina with the epithelium still there, it's like putting your hands together, right? It's not gonna scar, it's not gonna heal. You've got good epithelium. But if I peel all the skin off your hands and then go like this and leave you like that.
Kim (31:37.326)
Mm.
Kim (31:50.117)
Right.
Dr. Sonya Ephraim (31:56.066)
that's gonna scar and heal. Eventually you won't be able to take your hands apart. So I'm peeling that all off anyway so it's not that big of a deal. And usually someone who has a complete vault prolapse or a prosedentia, their opening is not small. I've got, cause of that weight of the prolapse and they've got an enlarged genital hiatus and so part of the procedure is also not just tucking the vagina back in but decreasing the size of that genital hiatus.
Kim (31:58.064)
Got it.
Kim (32:13.603)
Right.
Dr. Sonya Ephraim (32:24.79)
because if you leave it big, that increases risk for recurrence. So I essentially make the opening of the vagina small enough that if somebody needs to put a catheter in there at some point, they can find the opening of the urethra, they can void normally, but I make it like the size of one digit. Mm-hmm.
Kim (32:42.15)
Got it. Yeah. And you talked about some people having maybe an incontinence procedure at the same time, because there are some people who their prolapse can sometimes mask the incontinence, and once the prolapse is resolved, which with whatever procedure, then sometimes they still have incontinence. So if somebody did not, so say they didn't have incontinence, they've chosen this option. Is there, could this increase the risks?
Dr. Sonya Ephraim (32:52.863)
Mm-hmm.
Dr. Sonya Ephraim (32:58.593)
Absolutely.
Kim (33:09.69)
From the way you've described it, I think it would decrease the likelihood of incontinence developing, but do you see any correlation there?
Dr. Sonya Ephraim (33:17.742)
So if I'm understanding your question properly, someone comes in with a prolapse, a prosedentia or a vault prolapse, and decides on a colpectomy and then after they have the procedure will they have incontinence? So most likely yes, they will. And so in my practice I test for it first. Either they already tell me they have it because maybe they've been using a pessary for years.
And they're like, oh yeah, when my pessary is in, I leak terribly. And I'm like, okay, well, we need to do an incontinence procedure. Or if they have not been using a pessary, then I will reduce their prolapse with my hand or a speculum or something and have them cough. And usually urine is flying across the room, you know, cause the urethra is so weak. Or we can do urodynamic testing before surgery to try to see if we can kind of.
We put a pessary in during the test to push everything back and see, re-approximate what it's gonna be like after surgery. So I try to go into surgery very prepared and knowing, and then I have that discussion with the patient. Like my recommendation is we fix this cause you're not gonna be happy if I go through this big surgery and afterwards, the bulge is gone, but you're peeing all over yourself. So we try to address everything at the same time. But like I said before, usually if you've got a big prolapse like that,
then your urethra is not well supported. And it's 99% sure that you're gonna have an incontinence problem.
Kim (34:47.334)
Right. And what about UTI? So again, looking at this as the post-menopausal population, some people use estrogen, some people are not, some people may have recurrent UTIs. Does this change the occurrence rate of UTIs at all? And does it change, like there's still benefit to estrogen outside. And again, you said there's a tiny little, you know.
Dr. Sonya Ephraim (35:12.59)
Mm-hmm.
Kim (35:13.802)
space where you could go inside? Would it reach receptors at all? Is there benefit to that? Would they still stay using vaginal estrogen?
Dr. Sonya Ephraim (35:20.722)
Estrogen is wonderful for everyone. I think it's great. Estrogen is your friend. So I would never tell anyone not to use the estrogen. I think a lot of people who are getting urinary tract infections because of a large prolapse, oftentimes it's because of incomplete bladder emptying. So they've got this residual that's stagnant urine sitting there that's getting infected.
Kim (35:23.27)
Hehehe
I agree.
Dr. Sonya Ephraim (35:47.69)
Very often once they are able to empty completely then the UTI's aren't so much a problem anymore but I Hand vaginal estrogen out like candy. I think it's great. So everybody should be using it
Kim (36:00.79)
Yeah, I know. I'm starting to say it's almost like an essential nutrient. So yeah, yeah. Amazing. That's so interesting. And thank you so much for your time, for your work, your care for women. Where can people find you and learn more about your clinic and your work?
Dr. Sonya Ephraim (36:04.187)
Yeah, yeah.
Dr. Sonya Ephraim (36:17.266)
Well, my office is located in Deer Park, Illinois, so just outside of Chicago, and you can find me. My website is www.allure, A-L-L-U-R-E, pelvicwellness.com. And I'm also on all the social medias with TikTok, Instagram, YouTube, at Allure by Dr. Sonia. Well, thank you for having me.
Kim (36:41.786)
Amazing. Thank you so much. I really appreciate your time and I think everybody will really benefit this from this episode. Thank you.
Dr. Sonya Ephraim (36:49.138)
Absolutely, thank you so much for having me.
