Kim (00:02.34)
Hello, Dr. Elber, thank you so much for joining me on this week's episode. I'm excited to chat with you about all things pelvic surgery. It's a topic I get asked about a lot, and it's an area that you spend a lot of time in. And yeah, so I'd love first just to hand it over to you and talk a little bit about your background, what led you down the path of becoming a physician and then specializing in female pelvic health.
Dr Karyn Eilber (00:28.226)
That's a lot to cover. Well, being a doctor, you know, just trying to be, of course, like, you know, the dutiful daughter and actually my, I have two sisters who are also doctors, no doctors in the family. So for whatever reason, my parents got us all interested in medicine. And I had no idea what type of a doctor I wanted to be, which, you know, the way the medical school is set up is actually good because you get exposed to a lot of things. And...
Kim (00:30.774)
No.
Dr Karyn Eilber (00:55.206)
One of my first rotations was OBGYN, and I really loved working with women. I mean, obviously just because the two of us are having this conversation, I think we're both big female advocates, but I'm also very type A, and so having the obstetrics part where it's like very unpredictable was not really that attractive to me. So I found out that you could actually be a female pelvic surgeon if you were a urologist also.
So back in the day, they didn't have the designation of what my specialty is called now, which is female pelvic medicine and reconstructive surgery, AKA urogynecology. So if you see a urogynecologist, they can either be urology-based or gynecology-based. And the reason that I just did urology was I also do male pelvic reconstruction, not as much as my female patients. And I also just enjoyed doing a lot more abdominal surgeon again, just didn't really wanna spend my training.
doing obstetrics. No offense, I have three kids, so appreciate it. I like my sleep. The types of surgeries that are commonly performed, many women have stress incontinence. Although Kegel exercises can help, I think that is one of the biggest misconceptions that we tell women and it makes women feel bad because they're doing their Kegels. They're not always getting better and they feel like maybe it's because I didn't do them enough, I'm not doing them correctly.
Kim (01:56.656)
I'm going to go ahead and close the video.
Dr Karyn Eilber (02:22.43)
And I always love to use that analogy. If you tear the ACL in your knee, most people don't send you physical therapy, they send you your surgery. And if you have had vaginal delivery or other major pelvic surge or other things, it's not just a muscle weakness problem. So doing surgery for stress incontinence, I did two of those this morning. That's a very common thing to do. Just statistically speaking, one 11 women will have surgery for incontinence or prolapse in her lifetime. And of those, a third will have a re-operation.
just because there is no one surgery that lasts your whole life. If you have a great facelift, chances are you probably have to have another one in your life. And so prolapse surgery, falling bladders, falling uterus, whatever can fall out of there. What I am very fortunate to have where I work is I work very closely also with our colorectal colleagues. So women can also have rectal prolapse in addition, and that is not in my purview. So I will do those surgeries combined with colorectal surgeon. And I really feel like it,
If a woman has all those problems and she is often told she has to have two separate surgeries, she really, you know, it behooves her to do her homework and see if she'd go to a place where people can do it all at once because who wants to have two surgeries and two recoveries. And then, you know, just other small surgeries. What some people might consider cosmetic is labiaplasty, but some women it is not cosmetic. If you have a lot of excessive volar tissue or labial skin, women can...
reported tearing during sexual activity, even getting caught in their clothing. And so it's not really cosmetic in that sense. And then the non-operative parts, things that are done in the office. So for women who maybe have mild stress incontinence, there are urethral bulking agents.
So I practice in Beverly Hills and I love to use analogies. So some people need a facelift, which is what your urethral slings are for stress incontinence. And some people just need fillers. So there literally are fillers that are injected into the urethra to bulk them up. And that's something that can be done in the office. And many women, I think, get turned off from doing surgery, even if you do the surgery for stress incontinence. It is a half hour procedure. I typically do them with just sedation. So like a little twilight anesthesia.
Dr Karyn Eilber (04:35.19)
We let women resume exercise at two weeks, no sexual activity, full six weeks, but you can resume exercise in a couple of weeks. And statistically speaking, most women do great. The problem is, and back to the analogy, if you go to a restaurant and you have a really good experience, you have all intentions of telling everybody it's a great restaurant or posting a review, but you don't because you're happy and you move on with your life. If you get food poisoning, you're gonna post so many negative reviews so that everybody knows. So for the millions of women,
who have successful incontinence and prolapse surgery. You know, there are women who, of course, unfortunately are not gonna have the ideal outcome. And I think that those are the stories that get out. And I think it is a shame for women because they will suffer from these symptoms a lot because they've heard that story. My sister's cousin's sister-in-law had a bad surgery. And my response to that is, A, I don't even know if you had the right surgery. B, I don't know who did your surgery.
So that's another thing that I think is maybe a compliment as physicians that the general public tends to trust physicians and maybe doesn't do their homework. I think that people spend more time researching a car or a couch they're gonna buy than maybe the doctor that's gonna operate on them.
Kim (05:53.96)
Mm-hmm. Yeah. And it's, I think in the United States, it's different. So I'm in Canada and sometimes we have, it can sometimes be upwards of a year wait to see a urogynecologist or any practitioner for that reason. So the length of time it would take to see multiple practitioners, to interview them, to decide on the best one is sometimes prohibitive. And sometimes you have to kind of go with who you get referred to. So.
I like to say try to do your research ahead of time. So when you're going and asking for the referral, you're knowing who you wanna ask for, I wanna referral to this doctor rather than just waiting and waiting, waiting and then decide that you don't like that person.
Dr Karyn Eilber (06:34.314)
Yes, agreed. Although I have to say, and not live, disclaimer is I don't live in Canada, nor have I lived in Europe, but I do feel like the, it's more competitive being a doctor, I think in those countries. Be, well, you know, becoming, and I forget the terminology that they use in Europe, but.
Kim (06:48.949)
Oh really?
Dr Karyn Eilber (06:55.754)
It takes a long time to become what's the equivalent of like an attending physician in the States. And so a lot of those physicians that are from Europe will come to United States, do extra training so they can go back and get one of those coveted spots. And I have, I have lectured in Australia and they are much more critical of each other, which I think is good. It holds people to a different standard.
Kim (07:09.214)
Oh, interesting.
Kim (07:19.568)
Mm-hmm. I'd never even heard or thought about that before. Okay, so you kind of did a high level of some of the procedures that you wanna do. And so I wanna kind of hone in on a few of the more common ones. So you talked about you did some two incontinence surgeries this morning, and there's stress urinary incontinence, which is really what you're doing surgery for. There's no surgery for urgent continence, at least that I know of. Okay.
Dr Karyn Eilber (07:25.555)
Yes.
Dr Karyn Eilber (07:42.722)
Well, there is, there is. So I just wanna back up and do a little more on the stress incontinence, because one of the things that is very controversial, I'm sure you've heard, is the whole vaginal mesh thing. So stress incontinence, before mesh came about, and the way that it has been conveyed, you'd think that mesh was a new thing. It has been used for incontinence of prolapse surgery since the 90s.
Kim (07:55.908)
Yep.
Dr Karyn Eilber (08:10.498)
The issue that arose was around the early 2000s, several device companies made mesh kits to make the surgeries easier. I personally use them a lot and I like them. But a technology is meant to help someone who knows how to do a surgery do it better or easier. It is not in place of. So in fact, a lot of the complications that were seen, my colleagues and I did a research project that like,
75% of the vaginal mesh procedures were done by people doing one or two of those a year. So that goes back to do your homework so you know what it is. But the problem was there were a lot of women who really had some serious complications. I mean, myself, thankfully, and my colleagues who do this a lot, we did not have that experience. But unfortunately, the whole mesh debacle, which was really for prolapse and not for incontinence spilled over.
Kim (08:45.832)
Oh wow.
Dr Karyn Eilber (09:07.838)
Women should feel better that the FDA very carefully looked at mesh and all vaginal mesh products were removed But slings were not because slings have such high success rates and such minimal complications So the only alternative to doing a sling surgery is we can use a woman's own tissue It just makes sure a cover a little harder because you either have to do a bikini cut to take tissue from the belly
or from the leg, so it's not back to exercising in two weeks, and it's certainly an hour, hour and a half surgery versus 20 minutes, but it is certainly an option. And I do all of them and I offer the patients everything, but most of the patients, once you really tell them the statistics and the story about mesh, they will opt for a mesh length. It's just easier surgery and easier recovery. And success rates are over 90%. Again, no surgery is 100%, even if you have the perfect facelift, you don't look 18 again, unfortunately.
And also at over 10 years, the majority of women are still good. If you don't have as severe incontinence, let's say you just leak a little bit playing tennis, and not to minimize a woman's problem, but severity of disease has different treatments, that's when urethral bulking agents or fillers are appropriate. And I tend to do those in the office. We'll pre-medicate a woman with a little volume or something. You know, if someone tells me that they pass out the dentist's office, I will take them to, you know, surgery for real anesthesia for that.
just she'll be more comfortable. And that as far, so those are the main things for stress incontinence and for urgent. Yeah.
Kim (10:38.02)
Can you, sorry, before you move on to the urge, can we just, can we just, or can you elaborate a little on how the procedures are, how does the sling procedure performed? What are you actually doing? And then also in the bulking agents, where is it being inserted and what is it supposed to be helping? How is it helping?
Dr Karyn Eilber (10:48.162)
Yes.
Dr Karyn Eilber (10:56.522)
Yep, great question. So if you can consider stress incontinence is loss of support below the urethra. So if this is your urethra and normally there is this layer of support, if you cough or you sneeze, your abdominal pressure will compress your urethra against a fixed point. If you're missing that support, your urethra kind of aims down and the urine comes out. So a sling literally just recreates that support and the way that the sling is placed, there's a couple of different ways to skin the cat.
but the concept is the same. There is a small incision or cut made at the front part of the vagina, about an inch inside. And then there are passers that put the sling either in a U shape below the urethra or more like, I guess more like a half moon type of shape, and that just supports the urethra. What way you choose, honestly, is surgeon preference oftentimes. So a woman will have a small incision in the vagina.
And most slings will have two little, almost barely bigger than needle holes where the passers go through to pass the sling. The newer types of slings don't have exits. They actually just fixate into the pelvis itself. We call them single incision slings. So all you have is one incision inside the vagina. In that case, the woman, well, first of all, the woman doesn't really see her incision in the vagina anyway, all she would ever see would be the two exit incisions, which again are very small,
maybe an eighth of an inch, if that. But if she has a single incision sling, there is nothing outside. And most of my patients can get away with taking plain Tylenol or Advil after surgery. I do prescribe pain medication, but the biggest complaint is that they just feel sore. So if you show up to surgery, I mean, depending on the anesthesiologist's comfort, where I work, and we give a lot of local anesthesia, the patients really are.
are fine with just sedation. They like that because they wake up right away. There's no sore throat from having any tube in their throat for surgery. So they show up about an hour before surgery. Surgery itself is half an hour. You recover. We make sure you can urinate after surgery. In the past, all women who had an incontinence surgery would go home with a catheter. We don't do that these days. We allow every woman to try to pee.
Dr Karyn Eilber (13:12.342)
Maybe five, 10% may not be the same day of surgery. In that instance, they would come the next day and we'd have them just take out the catheter in the office. Fortunately, it is unusual for slings to be too tight. The woman has to have surgery to undo it. It does happen, fortunately less than 1% of the time, and it does happen.
Kim (13:31.056)
Okay, and it's, there's trans-ob, so T-O-T and T-V-T. Is the difference in those names, the difference as you said, either the U shape or the sort of the half moon?
Dr Karyn Eilber (13:42.75)
Yes, it's the exit. Yeah, it's the exit. So a TVT, the trocars or passers go from the vagina right behind your pubic bone. So to exit like the abdominal wall, whereas a TOT exits in the groin itself, like your skin fold right above the legs.
Kim (14:01.696)
it. Okay, perfect. That clarifies that. And as you said, it's that, I mean, mesh has been used in those surgeries for years and that really wasn't where sort of, as you called it, the mesh debacle was more in the prolapse side of things. So that is something that is still used very regularly.
Dr Karyn Eilber (14:20.814)
Correct. And like I said, I love to reinforce the patients, the FDA, I mean, there were hearings about these mesh products. And despite all of the research that was done and all the committees that were held, it was pretty well accepted that slings should stay on the market because again, they were so successful and the complications are so fortunately unusual.
Kim (14:26.744)
Yeah.
Kim (14:43.916)
Yeah, yeah. And because of the, like with any pelvic, like surgery or procedure, of course, I'm biased and I'm always referring to pelvic physio. But is that something that falls into your practice as well?
Dr Karyn Eilber (14:55.494)
I refer to Pelifor physical therapy every time I have office hours all the time. But you also have to be realistic with women. I mean, if a woman comes in wearing a couple of diapers, honestly, it's a waste of time. And I think you probably would agree with that as well. And if she has like severe, severe prolapse, you know, you can't really do physical therapy to fix that. But for sure, if someone has symptoms and her exam is reasonable, that's typically the first place to start. I mean, I don't think I definitely.
I mean, I'm a surgeon, of course I do surgery, but I think that always starting with the conservative approach first, because I've also been a patient. And I think that some of my consultations I have with physicians, I got turned off when right off the bat, they want to be very aggressive. I'm like, wait a minute. Yeah, I understand that maybe this is not going to be the most successful thing for me, but for my comfort level, I want to start with something conservative before I move to something more aggressive.
Kim (15:50.412)
Right, yeah, perfect.
Dr Karyn Eilber (15:51.094)
Now I know we have, I'm fortunate also to be in a town where we have a lot of really good pelvic floor physical therapists. You know, and you know this, which is what I do. When I started practice 20 years ago, you would be hard pressed to find a pelvic floor physical therapist. Or they were, you know, kind of general, or a general physical therapist who said they did pelvic floor physical therapy. Um, right, and I'd send patients for like, voiding dysfunction and they'd come back like,
Kim (16:04.74)
Yeah. Yep.
Kim (16:12.792)
Right.
Dr Karyn Eilber (16:19.51)
with more kegels, I'm like, no, that was the opposite. I wanted that to do.
Kim (16:21.38)
Yeah.
Kim (16:24.832)
Yeah, yeah, yeah. It's amazing. Actually, I started around the same time as you, obviously not down the medical path, but in sort of this pelvic health realm. And there were few and far between. And it took me a few years before I even had heard the term pelvic floor physical therapy. And seeing what's happened in the last kind of 10 years, I would say it's really sort of exploded. And still we have a shortage, really, but it's nice to see that there's a lot more.
a lot more awareness, a lot more practitioners, and also a lot more collaboration between the different healthcare providers too, which is amazing. So, okay, so those are the incontinence surgeries. And then you talked about the bulking agent, bulkomid is the name, is that correct?
Dr Karyn Eilber (17:08.738)
There's a couple. So bulkamid is like a hydro gel. I'm gonna get back to slings. The concept is the same. Whether you bulk with bulkamid or I actually use coaptite, which is calcium based, which has just been around for a lot longer. I'm just comfortable using it. And honestly, and hopefully the bulkamid people don't get mad. I was thinking about transitioning over and then the studies came out that the success rates are the same whether you use bulkamid or coaptite. So I wasn't really that motivated to change, but...
Honestly, it really doesn't matter what bulking agent someone uses, except, and I don't even think it's available in the market anymore, collagen used to be injected. But you know, collagen is not permanent, or it's not intended to be, and so women would have to be re-injected quite often. And the other thing is collagen can be extremely allergenic. So I've seen some women who had collagen injections who are worse because they got such inflammation in the urethra. So collagen, I don't even believe in...
actually available in our country. I don't know who's, you know, I'm sure people in other countries are gonna be watching this, but it's basically either Mulcomid, like again, which is a hydrogel, or coaptite, which is calcium hydroxyl apatite, or calcium-based.
Kim (18:20.064)
All those big names. Where exactly, yeah, where do you inject it, whatever it is that you're using? Where would you?
Dr Karyn Eilber (18:21.459)
Yeah, exactly.
Dr Karyn Eilber (18:27.494)
So it gets, yep, it gets injected into the bladder neck, which is where the urethra and the bladder connect inside. So in women who have stress incontinence, there are two reasons why we have total bladder control. One is our bladder neck, which we don't have any volitional control over. And that's typically what becomes weak with childbirth, aging, different things. And then our external sphincter, which is what we can kaggle. So that's why if you have a relatively decent bladder neck and you can get...
really strong external sphincter strength with pelvic floor physical therapy or using your kegels on your own, it's great. But for most women to be 100% continent, your external sphincter alone, again, which is what women can kegel, usually is not enough. You might be close, but people typically also need their bladder neck closed, which is where the bulking agent is injected. And the way that it's done is there is a cystoscope or a camera that goes inside, which I...
when we do it in the office, I tell the patients just don't even look at it. It looks really scary. And then there's a needle that goes through it. It's like the coaptite looks like toothpaste, quite frankly. And when you inject it, it's literally like, if your bladder neck is like this, you inject it and ideally it closes right up.
Kim (19:45.043)
And so that's like happens in a matter of seconds and then you're done and
Dr Karyn Eilber (19:47.774)
Yeah, literally like 15, 30 seconds. Yeah, and you're done.
Kim (19:51.244)
Wow, and then can people return to activity right away?
Dr Karyn Eilber (19:54.562)
there is no restrictions. So there is no special preparation. I do have, if we do in the office, the patients either have to Uber, someone has to drive them, because again, I give them volume or something else than a pain reliever. And we do the procedure. They just have to make sure they can urinate before they leave the office. But yeah, no restrictions at all after that. That's what's advantageous. Like if you're a candidate, which bulking agents really are most effective for mild, maybe moderate incontinence. So, you know, definitely a woman who only leaks, you know, when she's playing tennis, is the ideal candidate. If you're wearing maybe like a
well, one to three mini pads. But if you're wearing multiple pads, you're probably better off having surgery.
Kim (20:29.808)
Right, right. And so after the procedure, how long does it last and is this something that also would potentially need to be repeated?
Dr Karyn Eilber (20:38.626)
So most of the studies only go out to about three years. So we know that most people would last that long. And it's interesting that I have found that has played out in real life. So in fact, I just had a woman I re-injected who had it done almost four years ago and she was perfect till then. We did it and said, we were kind of laughing like see in four years. Theoretically, if it heals perfectly around because calcium is a permanent type material, it should last forever. But the problem at least...
this is what I think happens, the lining of the urethra is very thin. And I think it's like having a splinter below your skin. It will eventually kind of find its way out. But there are women who I think perfectly encapsulate or scarred inside. So in fact, I have a woman who I did years and years ago, and I just got a panic call from her because she had a cat skin for unrelated reasons. And she had a bladder stone. And I said, no, that's your coaptite because it looks like calcium, like a stone.
And I said, by the way, you're still dry. She said, yes. So there are definitely people, and she was many years ago. So if you are lucky and you perfectly scar it in, it can last a long, long time. But the data that is available, we say it'll last you at least three years, don't really know how much longer.
Kim (21:51.204)
Got it, got it, okay. All right, so then moving on to the urge incontinence, I sort of, I redirected you back, but let's go now to urge. So I am not aware of surgical procedures for urge incontinence, so I'm excited to hear what you have to say.
Dr Karyn Eilber (22:07.046)
In general, you are correct. Urge incontinence, which is part of overactive bladder frequency, urgency, incontinence is typically a medical disease. So behavioral modification. I tell patients, it doesn't matter what I do. If you're gonna keep drinking your four liters of Coke a day, it's really not gonna help you. So there is behavioral changes. I think that I send a lot of people to Peloponil physical therapy for overactive bladder.
And one of the theories of why it works is, or one of the theories even why we get overactive bladder is as we get older, as we lose our pelvic floor tone, it's that tightness that is a negative feedback telling our brain, hey, I don't wanna pee. But if you get weak, your brain thinks, oh, you're trying to relax and pee, let me help you out. So I do send a fair number of women to Pelvic Floor Physical Therapy for that. If women fail behavioral changes, Pelvic Floor Physical Therapy,
medications, then Botox injections are done into the bladder muscle. So if you imagine overactive bladder is a spastic bladder squeezing by itself and the medications are basically specific bladder muscle relaxants, but some people they have too spastic of muscle and that's when Botox is injected throughout the bladder wall. It's not necessarily a surgical procedure. Some people do bring their patients to surgery centers with sedation to do it. It's again something that I do in the office.
But for people who have overactive bladder and also urgent continence, there is what's slang term would be a bladder pacemaker. So it is a sacral nerve stimulator. And the sacral nerve is the main nerve that goes to the bladder as you know, but telling the audience. And the concept is exactly the same as the heart pacemaker. The difference is the lead or wire is implanted alongside the
third sacral nerve and we use people's anatomic landmarks, x-ray, and you know it's in the right place because when we stimulate or turn on the lead, your big toe will move and your anal sphincter will actually close because that's also the same nerve to those areas. And the nice thing about having that done, and it is, you know, when people have overactive bladder, right, you, fortunately you don't die from it. It is something that is a bother. So when you start throwing out things like implants.
Dr Karyn Eilber (24:27.426)
People are like, whoa, that's a little much for me. So the called sacral nurse stimulators, the first company to come out with it was Medtronic. And it's been out since the late 90s, but many people are unaware of it because it's just not talked about. There isn't direct to consumer advertising about it, but I typically implant one at least one or two a week. And just statistically speaking, millions of people have overactive bladder. And if you have it put in,
Kim (24:30.329)
Ha ha ha!
Dr Karyn Eilber (24:54.822)
Batteries can last anywhere from 10 to 12 years. So it'd be kind of nice to go to your doctor. You have an easy outpatient again It is done on outpatient just with some sedation The patient lays on their tummy because we have to access, you know their spine obviously from their back and the whole procedure to do the implant takes about 3045 minutes But if you could do that and not take medication and be good for 10 and 12 years And then even then to change the battery is like a 15 minute procedure
If you think about it that way, it's not so weird than thinking about, I'm going to have an implant for my overactive bladder.
Kim (25:29.356)
Right, right, right. Does it, do you have to be aware of going through like x-ray machines at the airport or anything like that?
Dr Karyn Eilber (25:36.434)
You know, people will tell the TSA agents that they have, you know, an implant, but because they look just like pain stimulators, they look just like heart pacemakers, and again, they've been around since the 90s. I've never had a patient be stopped at the airport.
Kim (25:49.464)
Yeah. You mentioned that you know it's working when the big toe moves and the anal sphincter closes. So could the same technology help with fecal incontinence as well?
Dr Karyn Eilber (26:02.534)
Yes, so the exact same device got indication, or such as smart, I love it. I love when you talk about people who like know about the vagina and all that stuff. Yes, the same device got indication for fecal incontinence. I can't remember like five or six years ago. So if you are someone who maybe has had spine surgery, whether it's Parkinson's, multiple sclerosis, different things that you got, urgent continence for the bladder, you got fecal incontinence.
Kim (26:08.08)
I'm sorry.
Dr Karyn Eilber (26:30.858)
this device can really be a game changer for people. And the one thing I did forget to add is we don't go straight to an implant unless we know it's gonna help you. Obviously nobody wants to have that done. So we do an office test where people will wear a temporary pacemaker for a week, and if they have at least 50% improvement in their symptoms, we will put the full implant in. And it's not the...
Kim (26:34.0)
Hmm, that's amazing.
Dr Karyn Eilber (26:53.446)
we only want people to get 50% better. It's just the test implant is not as good as the real thing. So if you have 50% improvement of the test, we know you're going to do even better with a full implant.
Kim (27:03.604)
Right, okay, that's amazing. I know that, you know, that you mentioned earlier, incontinence is a bother, and people can sort of put up with it for a certain period of time, and urinary incontinence. Fecal incontinence is much more, I would go beyond bother, it's much more life altering, and having more and more options for that, I think is really amazing. So, if we move away from the incontinence piece, and go now into prolapse,
In my experience, at least with the population that I work with, prolapse is the one that takes the bigger toll mentally, takes, I guess, more people are thinking about surgery for even immediately as soon as they get the diagnosis because they're so sidelined and they have been bothered often for so long thinking that there wasn't anything to do. And then when they finally learn about what's happening and get this diagnosis, they're put down the path of surgery.
but so many people just don't even know, first of all, what prolapse is, and then what all the different surgical procedures are. So let's start with the bladder. We'll kind of work our way through the different compartments, but if we start with the bladder, what's happening in a bladder prolapse and what surgical interventions are available?
Dr Karyn Eilber (28:18.718)
I think it is important for everyone to understand that prolapse, the term can be used interchangeably with a hernia, which is why typically a woman will say, you know, I feel great in the morning. As the day progresses, I have more pelvic pressure. Any symptom that a woman thinks is due to her prolapse should invariably be better at night. So I will see women for a consultation for prolapse surgery because she has pain all the time.
If she has pain at night and say, this is not your prolapse, you don't need surgery. So I think it is important to A, know that the prolapse is causing a symptom and B, it's all about the expectation. So I think that actually I find it the opposite. When people start having incontinence, that is when they seek help, but it is also a common misconception that you have incontinence because your bladder is falling when in fact they are two separate issues. So ironically,
This is the reef and this is the bladder. The more a woman's bladder falls, the less she has leakage. So if you talk to a woman whose bladder is really coming out, she'll tell you, yeah, I used to leak with coughing and sneezing and now I don't. So then if she has a pestery or a dish to support the bladder placed or she has surgery, she says, you know, I am leaking again and you're the worst doctor ever. So if you're gonna have your bladder lifted, right, make sure you tell your doctor, you know, what are you gonna do about preventing myocontinence? So.
Kim (29:36.656)
Yep.
Dr Karyn Eilber (29:43.622)
As far as the bladder goes, if it's only down a little bit, like stage one, stage two, and they just are bothered by a little bit of heaviness, those are ones that I really encourage you probably for physical therapy, because I think they're probably gonna have the same outcome. Now, if a woman's bladder is at the vaginal opening or farther, if she still has her uterus, you can't just lift her bladder. So I love the analogy of curtains on a rod.
So if you have your curtains on a rod and your curtains are a little bit longer because the hem came out, it's easy to fix the hem. But if your rod is down, that's why your curtains are longer, you keep trimming those curtains, but they're gonna keep coming down. So if a woman's bladder is really down, it's because the top of the vagina, which if a woman still has her uterus, is her uterus, or if she's had her uterus removed, we call it the vaginal vault, that also has to be addressed because if you don't fix.
your rod, if you will, you have a much higher chance of that bladder falling again. And for lower stage, you know, and most of these can be done actually through the vagina.
Kim (30:54.896)
Yeah. And when you talk about, you know, I've heard from so many people say, you know what, I finally tried a pessary and now I have incontinence. And, and I like the pessaries are almost like, if you're considering surgery, try a pessary first, because it could sometimes unmask incontinence. And then you have to, you know, you have other decisions to make, so to speak, and potentially have more things done at one time. So with what you're saying, then if somebody's uterus is like, if the, if the rod needs addressing.
Dr Karyn Eilber (31:03.216)
and
Kim (31:24.304)
There are some people who there said, let's just take the rod out, so to speak, take the uterus out and give them a hysterectomy. And then there's also increased risks of other types of prolapse when you remove the uterus. So what's your preference or default? How do you decide whether we should take the uterus out or do a suspension?
Dr Karyn Eilber (31:44.562)
If the uterus is, you know, maybe halfway down the vagina or not quite, I think it is easy enough to lift it up. Right? And you can just do that with sutures through the vagina. But it also depends on kind of what is your lead point. So when women come to have their prolapse evaluated, there's only room for one organ to stick out at one time. It doesn't mean that there's not more than one falling. So usually it is the bladder. But
for sure, if you go to examine her, her service is sitting right there, that's probably not a keeper. And it probably has to go because it's almost a little bit like a rubber band also. If it's so prolapsed and you try to lift it, there's so much redundant tissue that it just doesn't really look or hold very well. But I am not a fan of taking out organs if you don't need to. And I think another important point that you make is just taking out the uterus doesn't fix the problem.
So I've seen many women who saw someone and they had their uterus removed, but if you just remove the uterus and then don't do a procedure specifically to hold up the top of the vagina, you've really gained nothing.
Kim (32:47.812)
Yeah, yeah. So can you talk about that? So there's one term that I've heard for that, which is McCall's cul-de-plasty, which is suspending the top of the vagina. So are there multiple different techniques and how would you decide how to suspend the top of the vagina? And then just one final point is I've also heard that this is one reason why you would want to choose.
urologist or urogynecologist as opposed to a gynecologist because they have additional training in suspending the top of the vagina. Is that correct?
Dr Karyn Eilber (33:19.694)
Well, not just that, and of course we all like to tell ourselves, right? But not just that, but I think the urogynecologist will offer you all of the different ways. Right? So like if all you have is a hammer, all you're going to offer is to pat that nail in. But if you have lots of tools, you're going to offer different things. If a woman doesn't have that severe of uterine prolapse, and we're just going to lift it up, I prefer to do it through the vagina.
Kim (33:23.867)
Thank you.
Dr Karyn Eilber (33:47.314)
And I would do that with called a sacrospinous ligament fixation. Um, because the uterus is still there. So you're actually outside of the abdominal cavity. If you remove the uterus through the vagina, that's when you would do a McCall caudoplast because the McCall caudoplast, by definition is inside the abdominal cavity and you're taking where the utero sacral ligaments or where the uterus used to be attached. So that's the best way to do it through the vagina. Let's say, and you know, one issue.
Like one of the first questions I always ask women is, are you still sexually active? Because that also has implication of what you want to offer. And also, what is your goal? Do you want to have the most aggressive surgery with the lowest recurrence rate? Do you want to have one not so aggressive that has maybe a higher recurrence rate, but it's less? Do you have strong feelings about keeping your uterus or not? So if all things are kind of equal in the playing field, I think it's very important for the woman to make those choices herself.
So let's say it's a woman who her uterus isn't that prolapsed, but there's a family history of ovarian cancer or something else. Then we might lift up her uterus laparoscopically and take out tubes to prevent her risk of ovarian cancer or her ovaries in addition. So it really depends on other things that she needs. And there are women also who say, you know what? I really want to always have a tummy tuck. So then I'll just do it through a bikini cut, do our thing, and then have a passive surgeon come and close. So there are so many different ways to skin the cat.
You only get all those options if you're seeing someone who can offer you all those options.
Kim (35:19.888)
Right. Okay, so with, we kind of went to the uterus, but let's come back to the bladder. So what is the procedure if it was literally just the bladder? Well, potentially there's the hysterectomy or the uterus there too, but let's just say it's the bladder prolapse and it's a little bit more advanced. So there's, it's more than a stage one or two where, you know, again, referring on to physical therapy.
Are there multiple procedures that person could have and how would they, like what is or what are the procedures for a bladder prolapse repair?
Dr Karyn Eilber (35:55.554)
There is not really a lot of variation for just bladder prolapse, but if the bladder prolapse is severe, just lifting the bladder is not gonna solve her problem. That's how we got a little bit of side rails or with the hysterectomy and all that other stuff. But I tend not to fix low stage cystoseal because A, those tend not to be symptomatic. If a woman just feels a little bit or feels some pressure, for sure I send her to the physical therapist. The more common scenario is she's got stress incontinence.
And so we're there and then we'll fix that. And all that entails is, so if this is the layer below the bladder, it becomes separated. That allows the bladder to fall. So we open the skin of the vagina, find that layer and just sew it shut. And that is it. But if she has a higher stage bladder, let's say that prolapse is all the way to the opening of the vagina or even farther, you can't just lift the bladder, at least if you don't wanna have a high risk. That's why you have to do something to lift up the top of the vagina with it.
Kim (36:56.104)
it that makes sense and when you do I've often had this question after I went through I went through a posterior colporophy I can never pronounce all the big words but so incision in the back wall the vagina for erectus il yep and so they the front is essentially an anterior colporophy so then an incision and how does like what happens in a vaginoplasty is it also incisions into the wall
Dr Karyn Eilber (37:03.95)
Mm-hmm.
Recto seal repair, it's easier. Yeah.
Dr Karyn Eilber (37:24.582)
Vaginalplasty, yes, but vaginalplasty, it depends on how you wanna use the terminology. So like vaginal tightening or vaginal rejuvenation, some people will use the term vaginalplasty as well. That when you still typically make the incision in the middle of the back wall of the vagina and find that layer, bring them together. For me, vaginalplasty, you often do, unfortunately, if a woman's had prior surgery or radiation or vagina is too tight, then you actually make incisions to make it larger.
Kim (37:52.899)
Oh, interesting.
Dr Karyn Eilber (37:53.854)
Yeah, so vaginoplasty, it really depends on how you use the term. Technically, vaginoplasty is anything where it's like a plastics type of procedure, like reconstructive of the vagina, but people typically use it, at least for FPMRS or in urogyne. We talk about it as making the vagina larger because it's too small. Because really rectus ciliary repair, like if a woman wants to, and this is actually a good discussion. Sorry, we're jumping around a little.
But if a woman really feels like she has too much laxity, invariably she has erectus heel. And so that's why if you have the erectus heel fixed, that is your vaginal tightening or your vaginal rejuvenation. The difference is, and different healthcare system than Canada's, the difference is how you describe it and bill, it can either be a plastics procedure or it can be what it is, which is actually a prolapse procedure.
Kim (38:46.52)
Yeah, yeah, okay. That totally clarifies and sort of confirms what I was thinking. But okay, so that's the bladder. We've kind of discovered, we discussed the uterus as well, started talking about the rectocele. So rectocele is the rectum bulging in the back wall of the vagina. And as you said, a lot of people who experience that laxity often have that even though they haven't necessarily been diagnosed with a rectocele. They may not even know that that's what is contributing to that laxity. Is that fair?
Dr Karyn Eilber (39:14.894)
Correct. Yeah. But some people also just are, it's like any muscle in your body. Some people are just weak. And if people feel lax and they don't want to have prolapse, again, that's the perfect person to send to Pelvic Floor Physical Therapy.
Kim (39:26.06)
Yeah, yeah. And that repair is in the back walls I talked about already and pushing the rectum back, sew it up and then repair potentially the perineum as well. So is the perineoplasty, is that done both with anterior and posterior?
Dr Karyn Eilber (39:41.822)
No, so there's no equivalent of a perineurophy or perineoplasty for the anterior pair. Otherwise, we'd be covering up our urethra. And also, there are some women who just have a rectus seal, but their vaginal opening is fine. So those are oftentimes like my older patients who maybe are not taking hormones or are not sexually active, but they're chronically constipated. So they might have a rectus seal, but their actual vaginal opening is fine.
Kim (39:50.744)
Right.
Dr Karyn Eilber (40:09.154)
So if a woman again feels lax and she says, you know, I just don't really feel like my opening is normal, that's when she would have erectus seal and a perineuropathy or perineoplasty, whatever terminology you prefer. But some women have just erectus seal or perine, don't need a perineuropathy. And I especially do not like to do a perineuropathy if a woman has pain with intercourse already. Because even if a woman doesn't have pain with intercourse, unfortunately, any pelvic surgery does run that risk.
But in my experience, if you're gonna have pain, it's typically with a perineurophie and that area is always sensitive. I don't know if it's just because that's where women tear when they have vaginolivary, you know. The nerve innervation is no more rich there than any other place around the opening of the vagina. But man, when women have pain after surgery, it is always that. Like if I lift a patient's bladder or uterus, they're fine. You throw in the rectal seal with a perineurophie and they're feeling like they had a baby for a couple days. They're pretty uncomfortable.
Kim (41:05.86)
Yeah, yeah. I have a question about levator avulsion. Is this something that you screen for or see very often in your practice?
Dr Karyn Eilber (41:17.058)
I mean, by definition, probably every woman who has prolapse has some degree of levator avulsion. Unless you specifically get MRIs that will look at the pelvic sidewall that way, it's really hard to know. I have to say, maybe only once or twice in my career have I examined someone where they have such, it's like feeling nothing in that area, but every woman who's had a bachelor's degree probably has some degree of levator avulsion.
And that's also why pelvic floor physical therapy unfortunately doesn't fix everybody. Because if you have quite a bit of a bulshin, yeah, your muscles are there, but you're exercising muscles that are not in the right place.
Kim (41:56.28)
Right, right. Coming back to hysterectomy for a moment, I know there's also different routes or different ways to get at the uterus. You can go through the vagina, you can also go through the abdomen, also laparoscopically. So how do you make the decisions? What are the important considerations for what route would be best to remove the uterus if we're having a hysterectomy?
Dr Karyn Eilber (42:02.817)
Okay.
Dr Karyn Eilber (42:19.054)
So main consideration would really be degree of prolapse and if we're going to keep the uterus or not. So if a woman has severe uterine prolapse where it's sticking out, I mean, taking out through the vagina is so easy because it's literally sitting right there. But the problem is if she really wants her ovaries and tubes removed, you cannot guarantee you can access those through the vagina. So.
Kim (42:34.148)
Right there, yeah.
Dr Karyn Eilber (42:42.994)
because they're not directly attached to the uterus themselves, they're actually separate structures. So if a woman says, you know, I've got this strong family history of ovarian cancer, I really want my tubes and ovaries removed at the time of hysterectomy, probably should talk to her about doing it laparoscopically or abdominally, because you cannot guarantee, or you have to say, look, I'll try, but there's a possibility I can't do it. Or let's say, um, a woman has again, other things in her abdomen, then it might be better to do it abdominally.
If she has, say, recurrent prolapse and we're going to do something more definitive, which doing a sacral culpo-pexy does require use of mesh, that is typically a laparoscopic surgery or done with a bikini cut, is also preferred to keep the cervix if you do a hysterectomy in that setting. Because when you attach mesh to the cervix, it's nice, strong tissue. If you remove the entire uterus...
you have to sew the top of the vagina together and you have an artificial material on top of that new suture line and there is a risk of getting a mesh erosion or the mesh going through the suture line. So that's why it's preferred. But let's say a woman has had a couple abnormal pap smear in the last few years, it is really not appropriate to leave her cervix behind. She should have a total hysterectomy because otherwise you're leaving a cervix that we know has a history of being abnormal. So why would you give her that risk?
So there's a lot of things, the main consideration is, how prolapsed are you? What other repairs do we need to do? Have you failed a prior vaginal repair? Cause that's when you're also gonna be a little more aggressive and do something abdominally. Do you need other procedures done in your abdomen? And again, back to, I'm in Beverly Hills. Do you want a tummy tuck? Cause then we're gonna just do it open. It makes more sense for that. So many things to consider actually. And that's why, you know, women.
not to like betray like men's gender, but women are really smart. It's really fun to have these discussions. And the other great thing is, you would typically do a total hysterectomy in the past, but now we know that all cervical cancer comes from HPV. So if you have never had an abnormal pap and you're negative for HPV, you don't have to worry about leaving your cervix behind.
Kim (44:55.6)
Got it. Okay, and to finish off, let's go to the rectum. You mentioned earlier that you'll sometimes bring in a colorectal surgeon for a rectal prolapse. So rectal prolapse when the rectum is bulging out the anus. What is the, I know it's not what you do, but what is the surgical procedure that's done? And like, it's the same procedure. So you come in and how do you, do you go first and the other person goes next or how do you time it? Yeah.
Dr Karyn Eilber (45:19.986)
It's tag-teamed, yes it is. We're both there the whole time, it's a little bit tag-teamed. So typically if they have the rectal prolapse, the rectum is attached to the same place that we attach for sacral copalpexy, which is in front of a woman's spine in the lower lumbar sacral area. And just because urogynes do a lot more sacral copalpexies, at least where I am, I start, I'll do the exposure to have the area where we're gonna attach you to the spine.
I leave, then the colorectal surgeon, or I let the colorectal surgeon take over, they really mobilize or move the colon a lot because literally the colon is slipping down. So they want to be able to move it so they can pull it back up to where it needs to go. They sew mesh onto the front of the rectum. And I come back and if the woman needs her uterus taken out, whatever it is, do it that time also. And then I attach mesh to the top of the vagina and then we sew both pieces of mesh to the sacrum itself.
Kim (46:19.216)
Oh, okay, interesting. Yeah, I was always curious as to what actually, like as the rectum is being kind of drawn back, I never knew how it was actually kind of reattached or what was fixating it, what was holding it back where we want it to be, so interesting.
Dr Karyn Eilber (46:33.386)
Yeah, they actually literally sew a piece of mesh onto the rectum and pull it up where it needs to go. And some people who, there are some people who have really excessive or redundant colon and they will have part of their colon removed the time of surgery, because otherwise you can't just lift up something that's so redundant. So every once in a while, someone also has to have a colon resection at a time, yeah.
Kim (46:50.156)
Yeah. Oh, interesting.
Interesting, interesting. This was so informative. I so appreciate your time and the work that you do and sharing your wisdom with us. Thank you so much.
Dr Karyn Eilber (47:04.23)
Oh, I appreciate you. It's, it's so fun. Hopefully we didn't get too technical for everybody, but I think that, you know, women's health is something or women's pelvic health, I should say, is something that unfortunately women are not aware of until it's a problem. So one of the PAs that I work with, who I'm hoping to bring her into my practice to, we'd really love to start really a peri-partum program. We should have women starting their pelvic floor exercises before delivery, continuing, but we.
Kim (47:32.176)
Hallelujah.
Dr Karyn Eilber (47:34.426)
Nobody does that and you know women are not really told what to expect and it's not that they wouldn't have bad delivery. Everyone wants to have a baby but I think a lot of women feel very blindsided because they had no idea or when you're 50 it's hard for you to comprehend that wait a minute this is because I had babies I don't get it like nobody told me. So yes I appreciate and it's amazing how much awareness you have drawn and it's also just great that
Kim (47:53.752)
Yeah.
Dr Karyn Eilber (48:00.95)
Women have a place to go to that's not really so scary and scary, you know, to get some information.
Kim (48:05.004)
Yeah, yeah. Where can people find you if they want to learn more about you and maybe come to your practice and see you?
Dr Karyn Eilber (48:12.214)
They can just look up my name, Karen Eilbert, E-I-L-B-E-R. I practice in Beverly Hills. I work for Cedars Sinai. And there are many Euroguides across the country. And if you don't live in LA, feel free to send a message. You can actually help me email me, karen.eilbert.cshs. So CS and Charlie, S and Sam, H is in house, S and Sam.org. And I'm happy to help you find somebody. And we've got colleagues all over the country to help.
And even if you live in other countries, still no colleagues. It's a pretty small world, but we're here to help.
Kim (48:44.504)
Yeah, that's amazing. Thank you so much.
Dr Karyn Eilber (48:48.622)
Thank you.
