“Incontinence: Very Common, Very Treatable” – with Dr. Alan Garely

Dr. Alan Garely, a urogynecology specialist, explains urinary incontinence. In this episode, he and Dr. Fox discuss the urogynecology specialty, common causes for urinary incontinence, surgery, and treatment options.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. 


All right, we’re here with Dr. Alan Garely who’s a professor of Obstetrics and Gynecology at Mount Sinai, a specialist in urogynecology, the chair of OB-GYN at Mount Sinai, South Nassau, and he sees patients in the same office as me. Alan, welcome to “Healthful Woman.” It’s so glad to have you on the podcast. 


Dr. Garely: Thank you so much for having me here, Naty. 


Dr. Fox: Very nice. And so we were also discussing before, and the proper pronunciation of Garely and you were gonna say that your name is invented. And so, we need this on the podcast. 


Dr. Garely: This is true. This was an Ellis Island special. And my family had emigrated from Russia. And I guess, they had someone from Ireland who was checking them in because there are some Garelys in Ireland. And since nobody knew the name before it was given to us, half the family says Gare-ly, the other half says Garely, and nobody cares. 


Dr. Fox: What was the name in Russian? Do you know? 


Dr. Garely: It was sort of take off on Gorelik. It didn’t seem that hard to pronounce. 


Dr. Fox: We had that in our family. My mother’s father’s father, his name was Nathan Nathan because when he came on Ellis Island, they couldn’t pronounce his last name, and so, Nathan Nathan. So, the Nathan family was created in Ellis Island. 


Dr. Garely: Makes sense. 


Dr. Fox: That’s how it happens. Very nice. So, explain who are you? What is the urogynecologist? What do you do? 


Dr. Garely: So, a urogynecologist is basically somebody who figured out how to do operations that people used to do very badly. 


Dr. Fox: All right. So you’re one of the first people who is good at what they do. All right. 


Dr. Garely: So the specialty came about because everybody had an idea on how to fix pelvic floor disorder, incontinence, prolapse. And so a group of people back, I guess, in the early ’80s, started an organization that specialized in pelvic reconstructive surgery. At the time, up until probably the mid ’90s, we had about anywhere between two and eight people in the country training at any time. Total. Not in one program, but total. 


And in fact, when I started to go into urogynecology, as it’s popularly known, a lot of people that I was working with and training with had told me that this was not gonna be a good idea, which wouldn’t be my first bad idea, but that I wouldn’t be able to make a living doing this because everybody can do this. 


So, as the specialty developed and became more advanced, we started to specialize in surgical procedures that were more difficult for people who were still delivering babies and passing out birth control pills, and doing general obstetrics and gynecology. And by the early, I’d say by 2000 or so, the specialty had really come on in its own. And then we had worked tirelessly for probably another 12 or 13 years until urogynecology became a recognized subspecialty of the American Board of Obstetrics and Gynecology. And our formal name is female pelvic medicine and reconstructive surgery. 


Dr. Fox: That’s a lot. 


Dr. Garely: It is. So, I just like to say… 


Dr. Fox: You need an acronym like MFM. It’s simple. 


Dr. Garely: FPMRS? I don’t like it. 


Dr. Fox: No. 


Dr. Garely: I just like urogyn. 


Dr. Fox: Yeah, urogyn is definitely easier for simple people like me to remember. How did you get into this? And start from the beginning, like, where are you from, how did you get into medicine in the first place, and then we’ll get all the way to where you are today. 


Dr. Garely: So I sort of took a few turns to get here. I started off in always wanting to be a doctor. And when I was in high school, I got into a seven-year medical program at University of Maryland. After my first year, I hated it and decided I didn’t wanna be a doctor. And I said I wanna do something more in international work, not medicine. And I transferred to Hampshire College in Amherst, Massachusetts. And then, I had taken a leave to do internship with the State Department, with the Agency for International Development in Mali in West Africa. 


And when I was there, I got interested in some health issues, like public health stuff, and was developing oral rehydration for pediatric diarrhea. And this was very interesting work because you could save people who were gonna die with very little investment. All you needed was some salt and some sugar and some water and things were good to go. 


So, then I came back and did my undergraduate work and then did another leave with Johns Hopkins School of Medicine on an Indian reservation at the Apache Indian Reservation in Whiteriver in Arizona. 


Dr. Fox: Really? I did not know that. 


Dr. Garely: Yes. I was there for seven months after spending almost eight months or nine months in West Africa. And so then I continued a lot of the work I was doing from Africa, I was doing it in Arizona with the Johns Hopkins research center on the Indian reservation. And then, I decided I did wanna go to medical school. But by then, I had already dropped out of the seven-year program and I apparently lacked commitment and I ended up going to Grenada to St. George’s School of Medicine. 


I met some great people during my electives and my rotations in the States and was able to get a residency at the condominiums formerly known as St. Vincent’s down in the village. I went into OB-GYN thinking I would be a general obstetrician, just deliver babies. But something happened in my first year of residency which was I realized that I don’t like waking up at 4:00 in the morning. 


Dr. Fox: Right. Tough to be an OB if that’s on your docket. 


Dr. Garely: It wasn’t a good experience. So I quickly figured out a way… 


Dr. Fox: As you’re speaking to someone who was up at 4:00 in the morning today in that exact capacity. 


Dr. Garely: We all make choices and I don’t understand them, but I worked with amazing nurses who were more than happy to do my deliveries for me in the middle of the night as long as I would show up at the last second. So that worked out great. And my faculty there helped me develop my other interests which were surgical. 


Dr. Fox: Yeah, they say, “We better develop his other interests because he’s not gonna be delivering babies. God, we gotta teach this guy to do something.” 


Dr. Garely: I realized that infertility was not good for me because people cried a lot. I didn’t like crying. And I didn’t wanna do cancer surgery because, back then all the patients tended up to end up in the intensive care unit and that was also not a good place for me. And MFM was out of the question because I don’t like looking at television screens. So that really left the one specialty that… 


Dr. Fox: You know we do more than look at television screens, right? 


Dr. Garely: Apparently so. 


Dr. Fox: We do podcasts. That’s the other thing we do, we look at microphones. 


Dr. Garely: And they’re adding an extra year on to your fellowship, I think. You have everybody developed in this. 


Dr. Fox: I can promise you that at 4:00 in the morning, I was not looking at a television screen. So, you decided gynecology, surgical and then you got into the area of what we call urogynecology. 


Dr. Garely: Yeah. So, I got very lucky to get one of the eight spots in the country at the time. And I was really… 


Dr. Fox: And where was that? 


Dr. Garely: That was at the University of Connecticut. And after my first year of fellowship, my fellowship director decided to leave University of Connecticut and go to Einstein in the Bronx. And I didn’t really wanna go to the Bronx and I had been offered a second-year spot at a new program down in New Orleans at LSU Medical School. So, I had transferred down to LSU. And the person who was the fellowship director there was one of the leading people in the world on vesicovaginal fistula repairs, which was something I was very interested in. And my fellowship director at Connecticut was good friends with the guy in Louisiana and they agreed to this exchange. 


Dr. Fox: It’s interesting actually because you talked about vesicovaginal fistula the way that current residents in OB-GYN and probably a lot of fellows in, you know, pelvic floor and urogynecology learn about vesicovaginal fistula is actually by travelling abroad. And that’s because that’s where the incidence is much higher, you know, places like various parts of Africa and whatnot. And that’s where you started. 


Dr. Garely: It’s true. 


Dr. Fox: Why, you’re more interesting than I thought you were. 


Dr. Garely: Well, if we have some more drinks, Naty, you know, I’d become more interesting. 


Dr. Fox: No, you’re interesting after drink. And sober, you’ve never been as interesting. So this is… 


Dr. Garely: This is true. 


Dr. Fox: All right. So, that’s where you are and then from that point, how did you make your way to be such, you know, a big Maher? You’re the, you know, the chair of the departments. You’re a full professor. You’re a big guy now. 


Dr. Garely: Well, because in the land of the blind, the one-eyed man is king. And if you learn how to do something that very few people can do, it’s not so hard to sort of get advanced. Also, in my specialty, it’s so young that it’s not unusual for people like me to have served on the board of directors by the time I was 40. As opposed to your subspecialty, where people who have been practicing this for 20, or 30, or 40 years, it’s much harder to make a name for yourself when there are so many people ahead of you. That’s the difference. 


Dr. Fox: Okay, so you got in early. That’s good. So, again, what kind of conditions would women have heard about or know about that you treat specifically? 


Dr. Garely: Well, the most common ones are things like pelvic organ prolapse where the uterus or the vagina’s coming out from the opening. They would say they have a bulge. Also, incontinence when you leak urine if you cough, laugh, or sneeze. And then the things that are a little more technically difficult and different are things like problems related to transvaginal mesh, which were those kits that were implanted into people over the last 15 years and the FDA has pulled those off the market and a lot of people have complications with those. 


And then we also deal with complications from pelvic surgery, like fistulas that we spoke about, vesicovaginal fistula, holes between the bladder and the vagina or holes between the rectum and the vagina. And we also deal with people who were born with congenital absence of the vagina and then anything else that just requires surgery. 


Dr. Fox: Right. Now some of this overlaps a little bit with urology, right? 


Dr. Garely: And colorectal surgery. 


Dr. Fox: Right. And colorectal surgery. And so how does that sort of get navigated? Because you know, obviously, you’re treating women and then there’s urologists who treat obviously men and women. So, is it something where it’s like, there’s something you do, there’s something they do, or is it you guys have the same procedures and at different angles at it, or is it like competition? How does that work? 


Dr. Garely: Well, I can’t speak for the rest of the country, but in the New York metropolitan area, we have amazing relationships with all the pelvic surgeons, the urogynecologist and the fellowship-trained urologists who do this. I would say we all function really well. We have high respect for each other. 


There’s probably 90% of what we do is similar, but there is 10% that we don’t overlap with. And a lot of the urologists that are trained in pelvic surgery don’t like to do hysterectomy, so that’s a little bit of a rate-limiting step for them. 


Dr. Fox: Yeah, because the urologist, not training in gynecology specifically, just makes people uneasy about the gynecological aspect of this. 


Dr. Garely: And that’s why they’re not that many pelvic surgeons who are really trained on the urology side. Probably 90% are trained on the gynecology side. And the colorectal surgeons don’t like to fix pelvic floor disorders, they’re more interested in things like tumors and cancers. So we don’t really overlap a lot with colorectal unless there are fistulas, where they have to do widen [inaudible 00:11:10]. And then, they’ll do the cases with us. 


Dr. Fox: Right. So you just operate together? 


Dr. Garely: Correct. 


Dr. Fox: That’s interesting. That’s obviously a wide array of what you of what you do. But I thought we could focus on urinary incontinence because, I think, it’s a common problem and it’s, on the one hand, I don’t want to say a simple problem because it’s not, but it’s sort of, conceptually, people understand it, like what it is. And it’s something that’s not, so to speak, dangerous but it’s something a lot of people have and need fixed. And so, you’re gonna see a lot of people that I imagine. 


Dr. Garely: It is true. 


Dr. Fox: How would you explain to somebody what exactly incontinence is and why it happens to people or to women specifically? 


Dr. Garely: There are different ways of looking at it. One way of looking at it is sort of the physics of incontinence. Like, what are structural reasons? And then, another way of looking at it is the functional reason. So, to make it simple, and the best way to think about incontinence is that, if you’re just sitting and doing nothing and you’re not leaking, that’s because the pressure that’s in your bladder is not greater than the pressure that your urethra has to keep the urine in the bladder. 


So that urethra is basically the door to the bladder. The only purpose of the bladder is the storage and the elimination of urine. That’s it. And what keeps the urine in the bladder is the fact that the urethra, the door, is tight. So if you put all this pressure on the other side of the door, eventually, the door won’t be able to hold the pressure and the door opens up and the liquid comes out. So that’s a math problem. 


So if the pressure in the bladder is greater than the closure pressure of the urethra, you leak. A simple way of putting it, if you’re sitting here and not leaking, but you cough really hard and you leak, that’s stress incontinence. So coughing, laughing, sneezing, anything that puts a big stress on your bladder that causes the pressure to increase. Some people at some point, almost every person, will leak. So that’s stress incontinence. 


Another type of incontinence is called urge incontinence. That’s when we could just be sitting here and just doing nothing but watching television and all of a sudden, we have an urge to go and we can’t hold it. We can’t delay the ability for us to get to the bathroom. 


Either maybe we’re on our way to the bathroom, but we can’t even get out of the chair fast enough, our bladder basically has a spasm and causes leakage. That really doesn’t have as much to do with whether or not your urethra, the muscle that holds the urine in the bladder, is strong or weak. It has more to do with what’s going on in the bladder itself. 


Then the third type of leakage, of incontinence, is something called overflow. An overflow is what happens in people that have neurological conditions, where they don’t have a good sensation of whether their bladder is full or not. In those people, their urine just reaches a certain capacity in the bladder and just starts leaking out of the urethra. 


So, there’s three different types. And today, really for the purpose of your listeners, the two important types that we’re gonna talk about are stress incontinence and urge incontinence. 


Dr. Fox: Because they’re the most common? 


Dr. Garely: Because they’re the most common. And overflows is just not that, not common. And that’s something that has to be treated by people who really specialize in the neurourology. 


Dr. Fox: Right, because the bladder has the like nerves that innervate it and which is what gives you sensation to go. 


Dr. Garely: Correct. 


Dr. Fox: When you say they’re the most common, how common is incontinence in women? 


Dr. Garely: So it’s very difficult to get good epidemiological studies because of lack of reporting and good follow up. But the best estimates are that stress incontinence is probably the number one type of incontinence. And that takes place in about 35% to 40% of all women, mostly, who have risk factors. And the risk factors for incontinence, the number one risk factor is having had children vaginally, natural, you know, normal vaginal delivery. 


The second most common is urge incontinence, and that would be in the realm of probably 25% to 35%. And then there’s what’s called mixed incontinence, which is the overlap of stress incontinence and urge incontinence in the same patient. And that probably can comprise maybe 50% to 60%. So among the female population, all of these incontinence types are extremely common. 


Dr. Fox: When you said that originally, that the stress incontinence is 35%, that’s of women who have incontinence? 


Dr. Garely: Correct. 


Dr. Fox: But of all women, about what would you guess about how many of them will be dealing with incontinence at some point in their life? 


Dr. Garely: Probably a third. 


Dr. Fox: Yeah, I mean, it’s very, very common because many women have children and it’s a big risk factor. 


Dr. Garely: Well another thing about it is that from an evolutionary perspective, if you look back over 150, 200 years ago, the average life expectancy for people was their low 40s or upper 30s. Only in the last hundred years have we expanded our life expectancy to over 70. And because of that, these conditions would not have occurred in younger patients. But as tissue becomes less estrogenic, meaning people hit menopause and they’re not making estrogen, which helps the tissue stay healthy, then the incontinence increases. 


Dr. Fox: When people come to you. What is it about the incontinence? Is it just that it upsets them like because it’s socially, obviously, or is it that they’re worried that there’s something wrong with them, so to speak? What is the reason people come to seek treatment for this, typically? Like, what’s in their mind? 


Dr. Garely: I think almost the overwhelming percentage of patients come because it’s affecting the quality of life. It prevents them from engaging in activities that they want to do, whether it involves exercise or whether it involves being in social settings where they are afraid of wetting themselves. It’s usually some component of effecting lifestyle. 


Dr. Fox: Right, because it’s not typically, I mean, dangerous, obviously. It’s just, it’s quite annoying. 


Dr. Garely: Well, we always say, the only time is dangerous is if it causes a problem. We have to wake up in the middle of the night and it’s pitch black and you trip on something. And this is actually, it sounds superficial, but it’s actually a serious concern among older people. 


Dr. Fox: No, that does make a lot of sense. And then, in terms of when you see these women, how do you how do you evaluate them to figure out a, what’s going on? You know, what the causes might be and what the possible treatments are? What kind of evaluation would someone undergo? 


Dr. Garely: Well, it’s what we call a typical history and physical. And there are, but actually only a few questions we need to ask to sort of get an idea of what’s going on. Questions are, do you leak urine if you cough, laugh or sneeze? If the answer is yes, that’s almost always gonna be stress incontinence. Do you ever feel like you have to run to the bathroom and you can’t make it? That’s almost always urge incontinence. Do you have to wake up at night to pee? That’s called nocturia, and that’s usually either associated with incontinence or it can be a pre-incontinent condition. Do you have to go to the bathroom frequently during the day? And by definition, frequently is seven or more times a day is frequently. And do you ever feel like you don’t empty your bladder all the way? 


Now, if you have frequency and waking up at night, nocturia, those are things that usually will lead towards urge incontinence but not always stress incontinence. But something interesting happens, which is, some people, when they have stress incontinence, when they leak with coughing, laughing, or sneezing, it only occurs when their bladder is at a certain volume. 


So as a behavioral modification, what they do is, they say, “If I wait an hour, and then I cough or sneeze or exercise, I’m gonna leak. But if I go to the bathroom within 45 minutes of peeing, then I won’t leak if I cough, laugh or sneeze.” So what happens is people have behavioral modification where they start increasing their urinary frequency. And this causes them to have another type of overactive bladder. 


Dr. Fox: Because the bladder sort of “learns” that it’s supposed to be smaller? 


Dr. Garely: Correct. 


Dr. Fox: Right. I mean, there’s something called bladder training, like the bladder can learn. 


Dr. Garely: Absolutely correct. 


Dr. Fox: That was always very interesting to learn about that. 


Dr. Garely: So aside from that, those questions that I just went through, those five or six questions, everything else almost is secondary, except for the exam. When we look at the pelvic exam, we’re trying to see if things are where they’re supposed to be, in the right position, or whether or not the person has some degree of what’s called pelvic organ prolapse. 


Typically, those are things like “My bladder dropped,” or, “My uterus is dropping,” or, “I have a bulge when I have to have a bowel movement. I have to put my fingers to help.” So if you have associated pelvic organ issues with the symptoms, that’s what determines how we approach fixing these things. 


Dr. Fox: Right and then what about in terms of the severity. I would imagine someone who says, “I only leak a few drops, if I’m doing something very vigorous, but otherwise nothing” versus someone like, “Every time I cough, it’s like, it’s horrible.” Is that related? Do you see that on the exam always or is it sometimes unpredictable? 


Dr. Garely: Usually, the exam correlates to what the patient is describing. But in our world, things are very binary, they’re black and white. You’re either positive or you’re negative. If you’re positive, even if it’s a few drops or if it’s like a fire hydrant, it still comes down to quality of life issue. And that helps us help you to determine what course of treatment that you want to pursue. 


Dr. Fox: You take a history, you do the exam, you had a pretty good sense of what is the problem they have. And sort of anatomically, what else might you do like in terms of testing before you decide how to treat? 


Dr. Garely: So, as part of the definitive method of diagnosis is to actually fill the bladder up with some water and have the patient cough and bear down. We do this both laying down. And if they’re negative, we have them stand up. Because if you’re really going to have a surgical intervention for incontinence, the onus is really on the surgery to prove that you’re treating the right thing. The worst thing you can do is do a surgical procedure on someone who would have benefited from just taking medication. So, this is called a system metrics. 


In the office, we have a quick way of doing it. We put a small, very, very small catheter into the bladder, and we fill your bladder up with water. While you’re laying down, we ask you three questions. Tell us when you first feel the water going in, which can be described as coolness, wetness, or just any feeling of sensation. Then the second thing we ask is tell us when you feel like you would normally want to go to the bathroom. And then the third number we look for is, you tell us when you’re really starting to get uncomfortable. We don’t want to torture you or cause you pain. Just tell us when you want us to stop. 


Those three numbers tell us, basically, whether your bladder is capable of holding normal volumes of urine. And once it’s at your maximum capacity, we pull out the catheter and we have you cough. We can do it either in series of small coughs going up to bigger coughs or you could just have the patient take one big cough and see what happens. If they don’t leak, then we have them stand up and we do the same thing. Once we have a definitive diagnosis from that test, then all the treatment options just fall into place. 


Dr. Fox: Got it. And so if someone does have stress incontinence, what are the treatment options for her? 


Dr. Garely: So, first line treatment options for stress incontinence are pelvic floor therapy, where you can work with a special physical therapist. They do special training in pelvic therapy where they teach you to do biofeedback and what’s called pelvic floor muscle training. A lot of times patients will say, “I listened to my doctor and I saw a video on how to do Kegel exercises.” 


Dr. Fox: Right. Kegel. 


Dr. Garely: Kegel. 


Dr. Fox: Who is Kegel? 


Dr. Garely: Dr. Kegel invented these exercises. And the problem with Kegel exercises is that most people, when they try to do Kegels on their own, without the help of a physical therapist, are really just tightening their butt muscles. It’s sort of the equivalent of throwing someone into a pool with a book and saying, “Read this and learn how to swim.” It’s not really doable. 


So you would have to go to a pelvic floor therapist. And even in the best of hands with pelvic floor therapy, you can expect, probably, a 75% to 80% improvement in your stress incontinence but cure is usually not what they ultimately have. 


Dr. Fox: Right. And then when you said biofeedback, explain what that means. 


Dr. Garely: So biofeedback involves a pressure probe that goes into the vagina, and it helps you to confirm that you’re tightening the right muscles around the urethra. 


Dr. Fox: And so when they’re doing the pelvic therapy and they say, “Okay, try to tighten the muscles.” It’ll say you’re doing it right, you’re doing it wrong, and so the people can… That’s the feedback that they get. 


Dr. Garely: Correct. 


Dr. Fox: So you’re saying that is a method of improving, but not typically curing. 


Dr. Garely: Correct. And that was probably a good option as a first line when surgery was much more invasive than what we have today. 


Dr. Fox: Are those preventative because a lot of these people recommend them in terms of preventing this from happening, the Kegel exercises, either like during pregnancy or after delivery, or those types of things. 


Dr. Garely: So there have been studies looking at whether or not this type of things are preventative. And the jury’s out. There was a study that was done in France a few years ago that was probably the most comprehensive study on the subject. And it showed that during the pregnancy, it probably did help. But then, within three to four months after the baby was born, it really made no difference on the incidence. 


Dr. Fox: Interesting. So probably not so helpful as a preventative measure or not very helpful. 


Dr. Garely: But for some people, they need to try everything possible before they consider medicine or surgery. And that’s fine. 


Dr. Fox: Okay, yeah, I mean, obviously, there’s no harm to it. 


Dr. Garely: None, no harm. 


Dr. Fox: And so if that does not work to the degree that she wants, what would be the next step? 


Dr. Garely: For stress incontinence, the next step would be surgery. And we have different approaches, but the traditional approach that’s the standard of care today is called the retropubic sling. And that was developed in Sweden, and like 1990s. And I traveled to Sweden and studied with the inventor of it. And I did the first TVT sling, that was what it’s called the tension-free vaginal tape sling. I did the first TVT sling in the United States in 1999. 


Dr. Fox: Wow. And this sling is basically meant to sit under the urethra to sort of hold it up, to support it, when someone coughs or sneezes or whatever. 


Dr. Garely: Exactly. The purpose of the sling is basically to act as a backboard under the urethra, so that if you cough, the urethra has something to compress against. And so, we call it a TVT, tension-free, because you don’t want it to compress the urethra when we put it in because that would cause obstruction. People wouldn’t be able to pee. So we lay it in very, very gently and loosely, and it has a 90% cure rate. 


Dr. Fox: Ninety-percent cure rate. Is that permanent cure or is that for X amount of time? 


Dr. Garely: So if you were in 90% that’s cured, 10 years later, 85% of that 90% will still be cured. 


Dr. Fox: Okay, so that’s a very high likelihood of not needing something for 10 years afterwards? 


Dr. Garely: Correct. 


Dr. Fox: And the operation itself is not something where people typically stay in the hospital. 


Dr. Garely: No. 


Dr. Fox: They have it and go home. Correct? 


Dr. Garely: Yes, it takes about 15 to 20 minutes in normal situations. Complication rates are extremely low. It’s not in the same category as what people may have read about or heard about called transvaginal mesh, which caused a lot of problems for prolapse repair. And the FDA had pulled that off the market a few years ago. So this, if you go on the FDA website, this is described as pretty much the safest approach for the treatment of stress incontinence. 


Dr. Fox: And is there someone who have had stress incontinence where you would, you know, examine them, talk to them, and say, “This is not the right procedure for you. You need something more than this.” And who would that be? 


Dr. Garely: So patients who need something more, you would still possibly do the same operation, but they would need more procedures done at the same. So someone who has a vaginal prolapse can’t have a sling by itself. They have to have the vagina reconstructed so that it’s in normal position, and then sling can be done. 


Patients who are not candidates for slings are people who have had radiation to the pelvis. Those are that you have to be very careful about placing slings. 


Dr. Fox: By radiation, you mean like treatment cancer. You don’t mean like getting a CAT scan? 


  1. Garely: I mean treatment for cancer.


Dr. Fox: Right, a lot of radiation. 


Dr. Garely: Yes, correct. 


Dr. Fox: And someone would obviously know that, if they have that. 


Dr. Garely: Most definitely. And you would know it too as the doctor. There are almost no other contraindications for incontinence surgery. 


Dr. Fox: Right. And then, it can be done on in pretty much women of all ages, which is great. And these operations you’re referring…? Like so this one and all the other ones, how many of them nowadays would be done by someone like you versus a general OB-GYN, currently, in 2020? 


Dr. Garely: So it really is, it’s geographic and region. In areas where there are fellowship-trained pelvic surgeons, there are almost no general doctors who do these procedures anymore. But in more rural areas, where there are not fellowship-trained pelvic reconstructive surgeons, it wouldn’t be uncommon for a general gynecologist, who’s done hundreds of these, to be allowed to do them. And I’m sure those people do them safely. 


Dr. Fox: Yeah, I mean, and most of it is about having the training and skill to do it. And so, if they’ve been doing them and they’re the ones doing them, that makes a lot of sense. Right now, how many fellowship training programs out there? You mentioned before there were eight, total, because we never said how many there are now. I know it’s a lot. 


Dr. Garely: Now, I think we’re probably somewhere between 40 and 50 in the country. 


Dr. Fox: A year or total? 


Dr. Garely: That’s total spots per year. 


Dr. Fox: Per year? 


Dr. Garely: Per year, yeah. 


Dr. Fox: That’s a lot. 


Dr. Garely: Total spots per year. 


Dr. Fox: What about the woman who has what you think is urge continence? 


Dr. Garely: So urge incontinence, assuming that the person doesn’t have any other associated pelvic organ prolapse, you can treat that really effectively, again, with pelvic floor therapy. And that can give you probably a 70% or 80% chance of significant improvement. Or you go to medication as first line therapy. 


Now with pelvic floor therapy, the reason people don’t like to do pelvic floor therapy is because it requires an investment in time. You have to go visit a therapist. It doesn’t happen overnight. Medication, on the other hand, will work very rapidly and very quickly. 


Dr. Fox: And the medication just takes away that urge? 


Dr. Garely: It does. There are two classes of drugs. One class of drug is called the anticholinergics. And that’s drugs like people might be familiar with: oxybutynin, which is Ditropan, tolterodine, which is Detrol, or Vesicare. And those drugs, they work really well. No drug works really with a higher efficacy than any other drug. The only difference is side effect profiles. 


And side effects for anticholinergics class of drugs are dry mouth, dry eyes and constipation. And lately, anticholinergics have gotten a lot of bad press because there have been some papers published where it shows that it increases the risk of Alzheimer’s. 


One of the drugs in that class has a less chance of crossing the blood brain barrier, which is trospium, which is called Sanctura. And that’s based on the structure of the drug. It’s less likely to pass through the blood brain barrier. But as general class of drugs, those drugs can predispose you to Alzheimer’s. 


Dr. Fox: Is that data strong? Because you would think that it would be so much confounding that women who take them tend to be older. And as you get older, you’re more likely to have Alzheimer’s. And were they able like properly control for those? Because that seems like an error waiting to happen with that kind of conclusion. 


Dr. Nathan: Well, I know you’re putting on your statistician hat right now. And I have to agree with you on almost everything you just said. But with the unknown risk, because the statistics are not strong enough, one way or the other, to refute it. Luckily, we have an alternative. And there’s one alternative called mirabegron, which are called Myrbetriq. And this class of drugs works on a different receptor than the anticholinergics and does not have associated neurological and cognitive risk. The biggest risk for that drug is it can cause a slight increase in blood pressure in some patients. 


Dr. Fox: Got it. So for women who have urge incontinence, essentially, since the problem is not structural, there really wouldn’t be a surgical treatment for it unless it’s what you call mix before, correct? 


Dr. Garely: Not entirely true. 


Dr. Fox: Oh, let’s hear it. 


Dr. Garely: Because, if you have failed pharmacologic therapy, meaning oral drugs, the next step is to give the patients either a Botox injection in the bladder, which can be done in the office, it takes five minutes, or something called sacral nerve root stimulation. Sacral nerve root stimulation is basically a pacemaker that goes in the person’s back. It’s implanted, a little wire is implanted in one of the little holes in your sacral bone behind your back. It doesn’t really hurt very much. It’s put in while you’re awake, it’s done in the operating room. 


But there are also another therapy where you can do something called posterior tibial nerve root stimulation, PTNS. That’s where we take an acupuncture needle and we put it through your skin and to a little nerve behind your ankle. And it’s hooked up to a little stimulator and you get stimulated once a week for half an hour. And that also helps it. That interfaces with the same nerve that the sacral nerve root stimulator, which is the pacemaker, does. But the pacemaker is a permanent implant. 


We try to do the poster tibial nerve root stimulator, the ankle one first. Then, we go to the Botox. And then, we go to the implant with the pacemaker. A lot of people don’t want to come to the office for the ankle ones so that we could skip that and we go right to Botox. 


Dr. Fox: And that works for months? 


Dr. Garely: So Botox, if it works, can work up to a year. But if it doesn’t work on the first injection, we wait 12 weeks, and then we give a second injection. 


Dr. Fox: Wow. That’s amazing. 


Dr. Garely: The risk of Botox is 10% to 15% of the patients can have short-term urinary retention. So you have to counsel them about that before they get the injections. 


Dr. Fox: Sort of the opposite or what they had right had originally? 


Dr. Garely: Correct. 


Dr. Fox: How would someone find a urogynecologist? How do you see patients? Is it they come to you directly because, you know, they saw you online or friend or is it always referred from a gynecologist or internal medicine, geriatrician? How do people find you? 


Dr. Garely: So it’s an interesting question because before the internet, almost 99% of our referrals came from physicians, 1% came from patients who had already seen a urogynecologist and told their friends. But as the internet has become more pervasive, probably 40% or 50% of patients now for every urogynecology practice find their doctors online. 


Dr. Fox: Right, because, you know, they hear about you and then what you do. 


Dr. Garely: They google the words. They know what they think they have, they google it, and they find us. 


Dr. Fox: Right, and I would imagine that for the majority of gynecologists, they’re happy you’re around, right? Because they don’t do these procedures, most of them. 


Dr. Garely: They are because, back in the old days, medical economics was a lot different. People didn’t want to give up cases and they wanted to do everything. But as the world became more subspecialized, and there was inherent risk to doing things that you didn’t do on a daily basis, and people realized that, “Probably, it wasn’t worth my while to block out an entire morning to do a 15-minute sling in the hospital, when I could stay in my office and still see a lot more patients in general OB-GYN.” Those are things that pushed the specialty into getting the patients without having to have a competitive issue with other doctors. 


Dr. Fox: Right, so you mean, your relationship with the area gynecologists is they’re happy to send you patients, you’re happy to see them and send them back? 


Dr. Garely: Correct. And the same goes the for the urologists and the colorectal surgeons. The urologists, the ones who don’t do this as a specialty, they wanna have nothing to do with these types of patients, because it’s just not something that they’re interested in. 


Dr. Fox: The last thing we talked about in regards to incontinence, which I think is such an interesting aspect because it’s so common, and the first is, do you find that a lot of women delay seeking treatment because they were either embarrassed by it or in denial or whatever it was? Or do you find that it’s like, in your practice, always the people, like the second they have an issue, they’re coming to? I’m just curious, what’s it like out there? 


Dr. Garely: I think it’s more of the former than the latter. I think more people are delaying coming to urogynecologists or seeking treatment from any physician because they’re embarrassed. The first thing people have to get over, when they come to our office, is that every other person sitting in the waiting room has the same exact problem, and that they’re not alone. 


And it just gives people such great relief to know that this is so common. And a lot of times, people don’t even know that other people had it until they mention it to people that they confide in and then they’re always told, “Oh, I had the same problem and I got it treated.” This is such a common story where people will say, “I’ve been just ashamed, I don’t want to talk about it. And I finally mentioned it to one or two of my friends, and I thought nobody had ever heard of it. And I’m always surprised to hear that my friends have had this problem and they’ve had it treated.” 


But that’s the difference between me and somebody like an infertility doctor because I happen to be very good friends with some infertility doctors. And so, if we go to a party, the infertility doctor, 10 people can come up to them and thank them, and kiss them, and tell them how great they are and they’re next to God for helping them have their children. And I could see 10 people at the same party who I operated on for incontinence, they didn’t wanna… 


Dr. Fox: “Nope, never met him.” 


Dr. Garely: “I don’t know you.” 


Dr. Fox: “Don’t know him. Never heard of him.” It still fascinates me because, you know, I take care of, obviously, pregnant women. And so many of them have this problem, you know, either during pregnancy, after they deliver, or when they’re done having children as they get older. I mean it’s so common. And I would bet it’s more common than one out of three. 


But a lot of women, since they consider it potentially or they convince themselves that it’s not such a big issue, because it only happens rarely or on small amounts or, “Only if I do A, B and C, but not if I do this.” But then, they stopped doing A, B and C and they sort of adjust their whole life, because, again, they’re like, “Oh, you know, it’s embarrassing, I can sort of manage without it.” 


But they don’t have to do that. Like, if they have any symptoms, they can get evaluated and, again, they may that doing the pelvic floor therapy gets them to the point where they’re fine or they may want to try the operation. Again, if it’s not dangerous, it’s not, like, you’re not out of work for a time, or it isn’t really just agreeing, you’re deciding for yourself, “I’m going to do this and I’m going to treated or I’m at least get evaluated.” 


Dr. Garely: True. I mean, if we do the surgery on a Thursday, people are back to work by Monday. That’s how fast the recovery is. 


Dr. Fox: Yeah, and I think that’s really, you know, important. And also, now that there are more of you out there, it’s not like you can’t get an appointment. It’s not you can’t get treated. You could see someone that’s an expert. And I imagine that most of you and your colleagues, it’s not like you’re just throwing surgery to everyone. It’s the people need it, they need it. And if they don’t, they don’t. No one will operate on someone who doesn’t need it. Because that’s like, that’s not good situation. It’s then you cause problems. 


Dr. Garely: No, in fact, one of the things that I think that really reassures patients is I always say to them, “Look, if you’re having any doubt about whether this is the right way to go, I’ll give you the names of people that I trust for second opinions. Don’t take my word for it.” But when things are, what they…it’s simple, what they are. And they are just so obvious, most of my patients, I would say over 95%, they don’t, are not interested in second opinions. They understand what the problem is and they understand how to fix it. 


Dr. Fox: Right, it’s really probably just a decision to get evaluated is probably the biggest hurdle, so to speak… 


Dr. Garely: First step. 


Dr. Fox: And get it treated. 


Dr. Garely: The first step to therapy is just recognizing your problem and getting it looked at. That’s it. 


Dr. Fox: Wow. That’s amazing. One of the last topics I want to talk about is so women having babies. And people ask us this question sometimes, “Well, if I have caesarian, instead of a vaginal delivery, am I going to not have these problems as I get older? And it’s hard for us to answer that question because the answer is, you know, “Yes, it’ll be less likely that you’ll have these problems if you have C-section versus a vaginal, but the question is, how much less likely?” Meaning, it’s hard to know that for sure. You know, being pregnant itself is a risk factor, even without how you deliver. 


How go about that? I mean, you obviously have a different angle because you see everyone on the other end of it. So what do you tell people when they ask you this? I’m sure people ask you this all the time. 


Dr. Garely: All the time. It’s a complex and multifaceted question and complex and multifaceted answer. 


Dr. Fox: It’s why we’re here, breaking it down. 


Dr. Garely: I’m here for you, Naty. 


Dr. Fox: Yeah, we’re breaking it down. If I can understand it, then I’m sure the listeners can. 


Dr. Garely: Well, I always figure, if I can understand it, the listeners can. 


Dr. Fox: That’s a fair point. Okay. 


Dr. Garely: So the bottom line is that I have taken care of nuns who have never been sexually active, they’ve never had a job, and they have had another prolapse and incontinence. There’s a genetic component, for sure, to pelvic organ issues. We haven’t really clearly defined what that genetic component is, but it is more prevalent among the Northern European White populations like the Irish, Northern European, Ashkenazi-Jewish, very popular. 


And patients that don’t have genetic predisposition, meaning, in their family, there’s no real history of hernias. Hernias are an associated finding that we have in patients with incontinence and prolapse. If your parents had abdominal, umbilical, inguinal hernias, you had this as a child, that puts you of at a higher risk. 


The question of whether or not you’re going to avoid getting a condition by having a C-section, the answer is most likely you’re going to mitigate your risk. You’re going to decrease it. But does it go to zero? Most pelvic surgeons would say it does not go to zero. You’re probably going to lower it, but we look at it a different way, which is, what’s your trade off? 


Dr. Fox: Right. You’re having surgery to maybe avoid surgery. 


Dr. Garely: That’s right. So what is your gain here? And I always tell people, if you have any desire to have more than two babies by C-section, I don’t have to tell you this, you could tell your listeners what the risks of repetitive C-sections are. 


Dr. Fox: Right. And it’s just this. Because, I think, a lot of people, when they come in and say, “Okay. A lot of people have C-sections and they seem to do okay. So I think that would be okay having one. I really don’t want to have incontinence.” And okay, there’s logic to that, but I think what people may not put in the equation is, the incontinence they would get from having a vaginal delivery is treatable by a less invasive operation. 


All right, so you’re saying like, “I’m gonna do a more invasive operation with a harder recovery to avoid the possibility of having to do a less invasive operation, which, obviously, doesn’t make sense. Because I think what people are maybe weighing is, “I’d rather have a C-section than be incontinent the rest of my life.” Like, that’s okay. Like, I would agree with that. But you’re not gonna be incontinent the rest of your life if you get treated. 


Dr. Garely: I would say, untreatable incontinence is very, very, very rare. It’s just not something that we see. 


Dr. Fox: So it means, eventually, it’ll based on what you go through. 


Dr. Garely: Correct. 


Dr. Fox: I really appreciate you coming. This is really interesting and educational. It’s nice to spend time with you also, learn about your… 


Dr. Garely: Thank you. 


Dr. Fox: …all the things that you’ve done in your life were just cool. But I think it’s really a good message for people that, how common this is, number one. That it’s not something that has to be embarrassed or ashamed about. This is something that happened to your body either from deliveries or from genetics or just from time. It’s totally treatable. And you should go get evaluated. There are people who do this for a living and they’re good at it, and they’re happy to take care of you. And they will find a way for it to improve or go away entirely. 


Dr. Garely: I also tell you that when you come see us, you know, we try to keep it light. We try to not stress you out and, you know, your office, especially. My assistant, Aretha, who’s amazing, and she, you know, makes patients feel comfortable and assures everybody that they’re not alone. And so there’s a big psychological component to this, but we help you get through it. 


Dr. Fox: Alan, thanks for coming on. We’ll have you again. 


Dr. Garely: Thank you, Naty, any time. 


Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. 


The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.