128: Leaking Isn’t Normal: Pelvic Floor Health, Surgery & the Mesh Debate

Pelvic floor problems affect a huge number of women, yet many suffer in silence, unsure what’s normal and what isn’t. In this episode, we’re joined by Consultant Obstetrician and Gynaecologist and urogynaecology specialist Breffini Anglim O'Regan to break down everything you need to know about pelvic floor health, from prolapse and urinary incontinence to the real impact of pregnancy, childbirth, and ageing. We explore the full range of treatment options, from physiotherapy and pessaries to surgical interventions, including a clear and balanced look at the mesh surgery controversy, what it is, why it was widely used, what went wrong for some women, and why it is still being used in other countries but not in Ireland. We also unpack why leakage is not something women should just “put up with,” the role of vaginal estrogen and why it is often misunderstood, how to know when to seek help, and what questions to ask before considering surgery, with the aim of giving women clear, evidence-based information so they can make informed decisions about their own bodies without fear, stigma, or misinformation. Learn more about your ad choices. Visit megaphone.fm/adchoices

Transcript

SPEAKER_00 0:01

This show is part of the Head Stuff Podcast Network.

SPEAKER_04 0:15

Welcome to the Baby Tribe. I'm your host, Afi Felkafash, genatologist, pediatrician, and lactation consultant. And my co-host is Anne Deharty, obstetric anesthesiologist. Alright, today's episode is one we want to do for a long time because we're talking about pelvic floor issues which affects a huge number of women and yet somehow sits in that category of we'll just suffer quietly and pretend it's normal. We're going to get into something that has caused a lot of confusion, fear, and let's be honest, anger, and that is mesh surgery. Now, depending on who you ask, mesh is either a life-changing innovation or one of the biggest mistakes in modern gynecology. So instead of shouting about it on the internet, we thought we'd bring in somebody who actually does this for a living. We are delighted to be joined by consultant, obstetrician, and gynecologist and sub-specialist in urogynecology, Brephney Anglomore Regan. Brephney, welcome. Thank you. We are delighted to have you on. I've been meaning to get you on the pod for a long time because I think urogynecology in general, but specifically pelvic floor issues in women, is not really spoken about, and a lot of women suffer in silence. So before I get into it, just we usually like to get to know our guests. So what got you into urogynecology?

SPEAKER_02 1:27

Well, what brought me into obstetrics initially in medical school is the obstetrics part of it. Because it was just it was just like high intensity and just like a real privilege to be involved in that in the delivery process and like sections and stuff, and I liked the idea of doing surgery. But then as I progressed through my training, um, I was with Mark Ski and Dana Limerick, and he was such a good teacher. And um, then when I went to Cork, I just really appreciated that it's not like gyne oncology, which is really difficult surgery, where this is this is what you do for this person. Like it was very much like this is the prolapse, and you just kind of have to like put the jigsaw together and fix it again. So it was there was a kind of a bit of art to it, and no one was the same, and the surgeries weren't too long, and it made a huge difference to people. Like my patients love me because they're not leak anymore and they have no prolapse anymore. And and yeah, surgeries aren't too long because I get really hungry. Genuinely, three, four-hour surgeries.

SPEAKER_01 2:28

I'm like, oh my god. No, but when you talk about your patients loving you because they're they have their continence back, like continence is such a fundamental social requirement. Yes, you know, it just changes the lack of continence, it changes people's lives. It's kind of God, I might get killed for saying this, but there's an element of like, you know, people who live with chronic pain and how it can essentially run your life. Yeah, this is like that. Like, you know, all the people who know basically where every halfway decent bathroom is in the entirety of like a hundred mile kilometer or a hundred kilometer radius of their home, you know, this kind of stuff.

SPEAKER_02 3:04

Well, in the extreme case, they don't leave their house. Yes. And like, or if they're going away like they finally got to retirement and they're like finally playing golf and they've got their handicapped in or whatever, but they know where every single toilet on the golf course is, or if they're going away with their girlfriends and they're like, Oh, I don't want them to see all the pads in my bag, and it's like, which is sad at that age that you care what anyone thinks of you.

SPEAKER_01 3:25

I know, and people who can't exercise because they think they're gonna leak in the middle of a class, or you know, there's so many it just it can just transform or really limit your ability to live.

SPEAKER_04 3:36

So yeah, absolutely. We're gonna get into all of that, but can you tell us what exactly is urogynecology? Because I'm sure a lot of people don't know what it is.

SPEAKER_02 3:43

So urogynecology is predominantly managing like prolapse. So prolapse is when um it's the vaginal tissue that's become weak, and then the organs that come down into that, so the bladder, the womb, or the rectum at the back will fall down into the vagina. So it's a hernia. Um and incontinence, so the stress incontinences, which is when you leak, when you cough, sneeze, walk, jump, it has the same risk factors as prolapse, i.e., a weak pelvic floor. And then you have overactive bladder, which is a I really need to go to the stroid, can't get there in time, and leak before I get there. But that's a third of women will have stress and overactive bladder, but they're totally different. And a lot of it is related to oestrogen. So it'll be in the peri-postmenopause that it'll like peak.

SPEAKER_01 4:29

And so, what causes like obviously the mechanism is there, so the overactive bladder or else that that hernia? What predisposes people to having either of those things?

SPEAKER_02 4:38

So a lot of it is genetic. You will find a lot of women who come in, I'll ask them, did your mom have prolapse or incontinence? And they and they will. So it's only about 10 to 15% of women have prolapse and 10 to 15% of women have incontinence.

SPEAKER_01 4:51

Okay.

SPEAKER_02 4:51

Um, so maybe 20% have both because there's a lot of overlying risk factors. Um, but it's not everybody, and there's a like a spectrum of it, um, and the degree of which it impacts you and how you can manage it. Most of the time, you will have to have had a vaginal delivery to have prolapse um stress and conscience you can have just by having been pregnant before it, and then the vaginal delivery will kind of might just push you over the edge sometimes. Um, and then you've got the factors that make everything worse, like any increase in interabdominal pressure, so obesity, chronic cough, smoking, constipation is a big one. So there's all those bad things as well.

SPEAKER_04 5:30

Yeah. I was under the impression that it was almost exclusively associated with peripartum being pregnant and having a baby that you'd get incontinence and prolapse.

SPEAKER_02 5:40

So the stress incontinence and the prolapse, yes, but the overactive bladder, no.

SPEAKER_04 5:45

Okay.

SPEAKER_02 5:46

But you can very rarely get someone who has um stress incontinence and they will typically have some kind of like connective tissue double-jointed disorder. Yeah. And I see them, but they're rare. But I that's all I do, so that's why that's why I would meet them, but it would be very, very rare.

SPEAKER_04 6:01

So for example, women that have never gotten pregnant, is the incidence of prolapse and incontinence less?

SPEAKER_02 6:08

Way less than 0.1%. Wow. But the overactive bladder isn't really related to pregnancy. Yes.

SPEAKER_01 6:14

Is that an estrogen-related thing, like or is it just a genetic thing, as you were saying?

SPEAKER_02 6:19

So it just kind of happens for no, like it's just idiopathic. So there's no, there's there can be causes for it like MS and like um upper motor neuron lesions, that kind of the the more complex Parkinson's, but the majority is just happens for no reason. But then what I see a lot is, and I feel like people are becoming, I don't know, well, I because of COVID and everyone always mentions it, people are becoming a bit more anxious, and there is higher levels of anxiety and depression and that kind of thing. So people do hold their tension and can hold their tension in their pelvic floor. And if you have a very tight pelvic floor, which typically you might have pain during intercourse, so when your partner goes in during penetrative intercourse, initially it'll be sore. You might be peeing more frequently, not emptying your bladder fully because you're not allowing your uh like pelvic floor to relax fully and therefore your bladder to relax fully. So that can also be a tight pelvic floor, can be a cause for overactive bladder, and you would see that in like endometriosis, irritable bowel, so Crohn's ulcerophilitis, interstitial cystitis, those chronic pain things.

SPEAKER_01 7:24

We had Eva on who before who was a physiotherapist who does a lot of physio for pelvic floors, and she was talking about people post-c-section who can have a period of hypertonic pelvis rather than that laxity that you get with the vaginal delivery.

SPEAKER_02 7:38

Because you're trying to protect your scar massively, and it's something that people just don't know about at all.

SPEAKER_01 7:43

This is it. This is it, absolutely. Um, and so if people have had c-sections before, can they have like a prolonged time of kind of a hypertonic pelvic floor that would predispose them to having kind of a hypertonic bladder thing, or is that something that just tends to relax over time? And it doesn't really matter.

SPEAKER_02 8:00

It depends if you let it spiral or not, or if you recognize it and treat it. And so the physios will it's about identifying it, and then the physios will teach you how to relax it, and then they teach you the breathing technique so that you don't prolong the cycle.

SPEAKER_04 8:14

I mean, do you feel that the 20% is maybe an under representation because a lot of women put up with it?

SPEAKER_02 8:21

Or I think a lot more people are talking about it now, and I have a lot more women in their like late 30s and 40s coming. Whereas back in the day when I was training, it was like old women.

SPEAKER_04 8:32

Yeah, okay. So what are the symptoms that women experience that they have to say, okay, this is not normal? Um, because there may be confusion as to what is normal. I mean, I don't know if there is normal leakage or not, but what what are the symptoms that women should be aware of?

SPEAKER_02 8:48

So leakage isn't normal.

SPEAKER_04 8:50

Okay.

SPEAKER_02 8:51

Um, a lot of people will leak in pregnancy. I leaked in pregnancy from about 36 weeks because you've got a big massive bump, loads of fluid, a baby, a placenta, um, and loads of pressure on your pelvic floor. So around 36 weeks, my first pregnancy I started leaking. And but then in my second pregnancy, it was way earlier. It was like easily 20 weeks. And I don't leak outside a pregnancy unless I'm really jumping hard on a trampoline. Or I've been drinking before I get on the trampoline.

SPEAKER_04 9:19

Um we do not in between. Which was the reason, which was the reason to get on the trampoline in the first place. Exactly. Exactly.

SPEAKER_02 9:26

Yeah, you can go to the physio antenatally during your pregnancy and they will help you with that. And it's really important to engage with physio early on just to recognize how to treat it and to do your pelvic floor exercises. And you can also, I would not commonly, but sometimes put in um incontinence pest reads for people that are leaking because they might want to go for a run or they want to go to the gym when they're still pregnant. So you can use them in pregnancy as well. Okay.

SPEAKER_04 9:49

So are pelvic floor exercises really important to try and reduce the chances of having those issues postpartum?

SPEAKER_02 9:56

Um I think there's no harm doing them, but if you have a tight pelvic floor, you can make it a hell of a lot worse if you're tightening your pelvic floor too much. So I would see that not a lot, but sometimes in my women who I've done prolapse surgery on, and they're like, Oh, I really don't want this to come back down, and they've they know that they can start their cagles, but they over-tighten and then they start getting pain, and then they start walking. Like if you're gr like center of gravity, your pelvis is off, then it'll radiate your hip, and then it's just like yeah, and so that will be rare, but you really I mean, to be honest, if you don't have stress and contents or leakage when you cough and sneeze, and you don't have prolapse, yeah, you don't really need to do yeah.

SPEAKER_01 10:38

Yeah, and the relaxing the relaxation component is really important because I remember that discussion before. It's like everybody's focused on the tight, tight, tight, yes, but they don't focus on the learning how to let it come back down to normal where the muscle can actually recover, so it just gets very tight and short rather than being able to maintain its optimal function of kind of keeping everything in place. Yeah, yeah, yeah.

SPEAKER_02 11:02

And it will affect your bowel movements as well. So you'll have incomplete barrel empting and fecal urgency, you'll like really need to go to the toilet if you get like a small urge. Okay.

SPEAKER_01 11:11

Okay.

SPEAKER_02 11:11

Like massive impact on everything, and then backflow constipation, the whole.

SPEAKER_04 11:22

Management options. Generally, I guess they're divided into conservative and surgical. And we had Eva Harvey on before where she talked about um pessaries and physio. So can you give us a quick overview of the conservative measurements first before we get into surgical correction?

SPEAKER_02 11:38

Well, like no one really leaves my clinic without starting VagFEM. Um so most people, if they're peri or postmenopausal, wouldn't need VagFEM. And the only contraindication really is if they're on an astrazole. Um and even people having active breast cancer treatment that aren't on an astrazole, like oncologists are like you can use.

SPEAKER_04 11:56

And that's vaginal estrogen.

SPEAKER_02 11:57

Vaginal estrogen, which does not get systemically absorbed, but it like adds collagen and elasticity to the vaginal tissues. And uh like there's also um estrogen receptors in the rectum, um, so also good for fecal and cottons and in the bladder, so for overactive bladder, so it has a big impact on that. And then if you have any dryness during intercourse, it will help with that.

SPEAKER_01 12:19

And then there's so much evidence for local um vaginal estrogen support. Yeah, I give it any of my patients breastfeeding as well. Yes, this is what I was about to bring up as well. Like, you know, breastfeeding because it's it's a relatively hormone, like estrogen deficient state. Oh, massively, you know, so uh people don't realise that. So there's all these women who are breastfeeding who have uh vaginal dryness, vaginal discomfort, um, difficulty in recovering continence, postpartum, all of those kind of things. Um, and part that is partly well uh exacerbated by the low estrogen when they're breastfeeding. So vagifem, vagifem, vagifem, vagifem. And it's not available over the counter here, but it isn't okay. Yeah.

SPEAKER_02 13:04

But you can get a prescription from any GP, any and our nurses, well, one of the nurse specialists in the coom is doing her exams to prescribe. So yeah.

SPEAKER_01 13:14

Okay, good. And it's a tiny little tablet that just sits that it just gets inserted into the vagina from a little it's like a little tampon. Order it's a tiny little thing, little pessary. Yeah, a little stick. Yeah. And it just supports that all of those estrogen receptors in the pelvis and helps them maintain all the tissue functions that they would like to maintain.

SPEAKER_04 13:35

Yeah. Can I can I ask you, what are the lingering misconceptions about vaginal estrogen?

SPEAKER_02 13:41

Breast cancer is the big concern. So all over the box it says it's H or T.

SPEAKER_04 13:45

Yeah.

SPEAKER_02 13:45

But it's and yes, it is hormone replacement therapy because you're replacing a hormone, but it's not systemically absorbed, so it doesn't have any systemic side effects. And now sometimes people like if you have someone who has very thin tissues initially when they come into you, you would start them on ovestine, which is a slightly higher overall it's a very low dose, but it's a slightly higher dose. Um and I would put people on that for a month if it's really thin and then change them back to vagifem because ovestin can be it's a cream, it's just it's a bit messy. Um, and they do sometimes get a bit of breast tenderness and they totally freak out because initially, when that vaginal skin is really thin, the Eastern could get a little bit absorbed into your system. Um, but then what after a few weeks the vaginal skin thickens and then the eastern no longer gets through. So if you maintain that thickness by using it twice a week, it's totally safe.

SPEAKER_04 14:34

Then when would you consider surgical intervention?

SPEAKER_02 14:37

So it's it's very much the it's not like it was back in the day. Like the patient, you go through all the different options, you always like exhaust conservative um physio. You will always try a pestry. A lot of people, uh especially with my younger woman, will be a little bit like, whoa, the size of that pessary. Um, but actually the elasticity and um the collagen in a pre-menopausal vagina allows a lot more space. Like even if you think when you orgasm, like your vagina, uh a baby's head fits through there and it goes back. So there is a lot of space there. So um I would usually, particularly in pre-menopausal women, I would try and use pessries a lot of the time because if they're pre-menopausal with prolapse, it's not just your barn door prolapse. They have like usually they're double-jointed or have another, they've a connective tissue disorder.

SPEAKER_04 15:24

And can you tell us what a pessary is?

SPEAKER_02 15:26

Sorry, a pessary is like um it's like a doughnut y ring thing. Okay, and it acts as a support, so it's like a crutch, you put it into the vagina, and it will lift up your prolapse. And then sometimes if you have stress and content, so leakage when you cough, sneeze, walk, jump, there's a little knob on it, and that just kind of supports the bladder neck, so at the where you pee out of and it Okay.

SPEAKER_04 15:48

And are women aware of it?

SPEAKER_01 15:49

If you can feel it, it's the wrong size. What about sexual function if somebody is wearing using a pessary? Like what is the situation with that?

SPEAKER_02 15:56

I t so anyone who like most people will be able to take a pessary in and out. Um the older women, like 70s, maybe not, but some of them do. Um, but usually I say take it out for intercourse. But then if women some people leak during intercourse, and then I will tell them to leave it in. Okay. Because it's sitting at the very, very top. Yes. So your partner could be aware of it, but like Yeah, it's not going to cause any harm and it shouldn't be.

SPEAKER_01 16:20

No, no, no, it won't cause any discomfort. And it's it's it's a a function and preference issue rather than a safety issue or anything like that. Yeah. Um, and there are oestrogen releasing pesseries, aren't there? Or is that mainly for an estrogen support rather than a pessary mechanism?

SPEAKER_02 16:36

There's an S ring which is just like a flimsy, it's not really pessimistic.

SPEAKER_01 16:39

Okay, it's not like a port, it's just another means of delivering the estrogen rather than um an actual support pessary.

SPEAKER_02 16:47

So could women be on both the Yeah, so you'd put the S ring in, particularly say if it's an older woman who has bad memory or whatever, you put the S ring and then you put the pestery.

SPEAKER_04 16:55

Yeah, so can you tell us about the surgical options that are available at the moment?

SPEAKER_02 16:59

For prolapse?

SPEAKER_04 17:00

Yes.

SPEAKER_02 17:00

Um, so it just depends what's coming down. So if you have usually all three compartments, so the front, the top, the back, will be prolapsing to a degree. Sometimes you might have an isolated recto seal, so the rectum uh prolapsing into the vagina if someone had chronic constipation and a poor diet. Um, but yeah, commonly it would be more the bladder. So the weakest, so the fascia is this connective tissue, strong fibrous tissue layer underneath the vaginal skin that needs to that's what you need for the support. And the weakest fascia is at the bladder. So that's typically the bit that comes down the most. And if it's if you do prolapse surgery, it'll usually last you 10 to 15 years, and it's usually the bladder that comes back down again because that's it's the weak link. So yeah, just basic physics, that's where it comes down again. So if the bladder's coming down, you it's mainly vaginal surgery, very non-invasive. Most women in their 70s, 80s, like they're totally grand, minimal pain afterwards because there's not there's just not as many nerve fibers there.

SPEAKER_01 17:59

Yeah.

SPEAKER_04 18:00

And that's a native tissue repair, so you're just repairing.

SPEAKER_02 18:02

All native tissue, yeah. You go in, you open up the skin, you repair the fascia, is the most important part. If you take the womb out, you reattach the top of the womb to ligaments so the top of the vagina doesn't come down. And then same you repair the back.

SPEAKER_04 18:14

That's for prolapse. What about uretery incontinence then?

SPEAKER_02 18:17

So for overactive bladder, I need to go, I can't get there on time. That's mainly medication. Yeah. So vaginal estrogen, bladder retraining, um, and then there's different medications that we can use, which generally um that in combination with the bladder retraining, it's a lot of it is habit and the like Irish women drinking 10 cups of tea, which is also really bad for your sleep, and then your deep sleep and the whole shebang. Yeah. Um, and your iron absorption, everything. Yeah, that's true. Actually, the tannins and tea. Yeah. And um, so sometimes like a lot of the time the time, say my public and I could they could be waiting like between 12 to 16 months to get to see me. So I will put them on a medication then, and then I do the bladdery training with them with a view to come off the medication. But sometimes people are really, really bad for whatever reason, and you might have to go down the Botox route. Botox into the bladder.

SPEAKER_04 19:09

Yes. And how often do you need to do that?

SPEAKER_02 19:11

Every four to nine months. And each time, so you build up antibodies to Botox, so each time um over time it lasts less, and you need to go up on the dose.

SPEAKER_04 19:21

Is that the same with face Botox?

SPEAKER_02 19:23

So my friend does loads of Botox, and she said you can build up antibodies, so you have to change the brand. So it probably is interesting.

SPEAKER_01 19:30

No idea about that.

SPEAKER_02 19:31

So for stress incontinence, which is leak when you cough, sneeze, walk, jump. Um, bulk amid is something we didn't use very often because the success is like 50 to 60 percent. It's not great for younger women who are like playing tennis and jumping around. It would be good for someone with mild incontinence, maybe once or twice a week who's older and they're not like yeah, doing strenuous exercise. It works really well. So it's like the knob in the pestry, it just acts as a support. So you narrow the opening and then you leak, but probably not as much, and you may not even notice then if you do leak at all. So basically, what the issue with stress incontinence is so one component is the pelvic floor that is weak, and then but sometimes you can have someone who has a really good pelvic floor, but the ligaments that are below the bladder neck, so that hammock of support that catches you when there's an increase in interabdomal pressure, when you cough, when you sneeze, when you jump, there's no backward support. So the surgeries that are um are done recreate that hammock, yes. So that's where the mesh TBT, um, which was brought in like in the early 2000s.

SPEAKER_04 20:34

Okay.

SPEAKER_02 20:35

So that's what that does. And prior to that, we would have been doing burtical suspensions and fascial slings. So the fascial sling is the same as the mesh sling, it's just use your own tissue.

SPEAKER_04 20:44

Okay, so what is mesh? Can you tell us about mesh?

SPEAKER_02 20:46

So mesh is what you use for hernia repairs.

SPEAKER_04 20:49

Okay.

SPEAKER_02 20:49

It's a polypropylene mesh, so it's a non-absorbable material. So the issue with uh with say stress incontinence and prolapse is the tissue is weak. So therefore, if you use your own tissue for stress and continence surgery, like the fascial sling instead of the mesh sling, over time. Like initially it's quite good, but over time because your tissue is weak, and that's why you're in the situation in the first place, the efficacy wears off and like it's not as good long term.

SPEAKER_04 21:16

At some point it was seen as a great solution. So, what actually happened with mesh?

SPEAKER_02 21:21

So back in 2018, there was a pause worldwide to put on mesh, and um and everywhere else in the world restarted it after it went through a rigorous review process. They basically here in the UK, and uh some of the trusts in the UK are doing it again, but we're the only places that are not doing it anymore.

SPEAKER_04 21:39

And what what was the issue with mesh?

SPEAKER_02 21:40

So most of it is pain. Okay. So um, but what they put a pause on vaginal mesh, which is any mesh put into the vagina. So you can do mesh for prolapse when the top of the vagina comes down, but you put that in through the abdomen. Um and similarly, the colorectal surgeons, if your rectum is coming out. They still put mesh on and lift that up through the, so they it's a laparospee, so keyhole in through your belly button and lift that up. Um, but you can also, some women, as I was saying, that fascia at the front where the bladder is is really weak. Sometimes on your like third surgery, if that's come back down again, people were putting in mesh in through the vagina, so not through the tummy, in through the vagina, and where that connects to, it's in around the sacrospinus ligament, which is where all the nerves and all the blood supply is. And if you hit or irritate those nerves, it can cause pain. So you have to be trained. So I spent two years just doing it because it's a very blind area, it's a lot of tactile feedback. Um, and you have to spend a lot of time just doing those same surgeries over and over to become comfortable in the area. So people were um so and like I suppose there's complications with everything, but pain is one of the probably the worst complications you can get. So there was a pause put on all of that mesh, and it included so the meshes for prolapse, vagina prolapse are quite big, whereas the mesh for stress and continence, so um is a lot, it's about a centimetre wide by about 12 centimeters in length. Okay, and where it's put in doesn't the risk for pain is significantly yes, but the Irish government just put a pause on everything.

SPEAKER_01 23:19

On everything, okay.

SPEAKER_02 23:21

Everything.

SPEAKER_01 23:21

Okay. Okay.

SPEAKER_02 23:22

And now what they're doing is they are so there's the treatment abroad scheme. So women um are travelling abroad. So the Irish government are like, yeah, you can't have this surgery here, but we have no issues about the safety of the surgery, and that's why they're doing them everywhere else in the world. And but you know what, we'll pay for you to go over to Europe somewhere, and you can have it done by a surgeon you've never you've met once in a country that doesn't speak the same language as you. Oh, and by the way, you can sort the appointment with the doctor and all your accommodation stuff and flights.

SPEAKER_04 23:54

That sounds bonkers.

SPEAKER_02 23:55

It is bonkers. Yeah, it's very important. But what's more bonkers, what's more bonkers is that there's a um obviously we're all very good consultants, but one of a very a very good consultant down in Cork who in his free time at the weekend he's going out to Spain and the Irish government are paying the Spanish hospital, who then indirectly pays him to operate on Irish women.

SPEAKER_04 24:17

Rather than just saying do it here.

SPEAKER_02 24:19

Exactly.

SPEAKER_04 24:20

Wow.

SPEAKER_01 24:21

And can I ask, was that related to kind of the litigation outcomes? Was there a series of cases or something that resulted in specific litigation paying payouts or something like that that meant that when they did a cost analysis that they were worried about the costs and the litigation related to it?

SPEAKER_02 24:39

Every surgery, like how many people have you met? Um, like how many people have you met have had a C-section of pain after it?

SPEAKER_01 24:44

Yeah, it's not uncommon. Three years of pain after my first C-section.

SPEAKER_02 24:48

Yeah. Or even a vaginal delivery. Yeah. Or a hip. How many hip or knee replacements are in pain? And it's not to say that uh that should be acceptable, but it is a known complication. Um, and I suppose now we have brought in the consent form. So I met with the National Patient Safety Authority office two weeks ago with two other consultants, and we have got a framework that we're working on through the National Women and Infants Programme to bring it back in. Um, but we've been working on this since like 2018. Yeah.

SPEAKER_04 25:21

And the original issues have been sort of rectified and sorted.

SPEAKER_02 25:27

So there's two mesh centres now in Cork and Dublin.

SPEAKER_04 25:30

Yeah.

SPEAKER_02 25:30

Um, and there will be us urogynecologists, we have urologists there, we have pain specialists, psychologists, physios, and we all go. And anyone who has a complication, we will discuss them and we will make a plan for them.

SPEAKER_04 25:41

Yes. No, I meant the original concern that prompted the world to stop mesh surgery, they're all sorted now, are they?

SPEAKER_02 25:49

Yeah, yeah, yeah. Well, there was a review of it, and then I suppose now only people that are trained to put it in can put it in. Yeah. There's a register of people who can. Um, it can only be done, everything will be more MDT'd, so discussed at a multidisciplinary team meeting before it's put in. There's lots of safeguards that will be put in.

SPEAKER_04 26:05

Was there maybe in certain situations a rush to put in a mesh when there wasn't enough training?

SPEAKER_02 26:11

No, I suppose it's like anything. If there's something new, like a robot, everybody wants to use it, or like a mesh, or like a different new device. Um yeah, that is probably a component to it.

SPEAKER_01 26:20

I think as well though, like when there's a new procedure, it does take time for the nuances to be hammered out over years and years and years of a wider implementation so that people can choose the right patients for the right procedure. Yeah. You know, um, and I think that's just a a period of education that happens um in any kind of healthcare system. Um it is interesting that it was a worldwide kind of halt on on vaginal mesh procedures, but the fact that they have like recommenced after very shortly afterwards, and there is a position statement from the International and the American Uragani Society saying this is safe to use. Yeah, so all of the due diligence has been done, and that's really important for people to know. Yeah. So if if somebody is talking to them about a mesh surgery, what are the things as a patient that you would tell them to have kind of ticking off in their brain as they're listening to it?

SPEAKER_02 27:16

So I suppose the first thing is you if you don't want mesh, you don't have to have mesh. Um, but you should be allowed to have the choice to have it in your own country if you want to have it in your own country. Um, because even traveling has like a risk of clot, and some people have way too many medical comorbidities and don't have childcare. Yes. Like it th, you know there's really complex patients that there's no way you can send them abroad.

SPEAKER_01 27:38

Um also just ensuring consistent follow-up in the same jurisdiction that you had your surgery with people who are familiar with exactly what's been done. It's really important. Yeah.

SPEAKER_04 27:49

Yeah. I mean, it sounds like some women are missing out on a treatment that they should that it should be available to them in their country.

SPEAKER_02 27:56

So now, so there's the four surgical options. So you've done all the conservative stuff, they've tried pesteries, and then so the consent form now, um, and you would also give them the international patient information need for this, and they spend time reading it and they come back to clinic and they will decide, and it's like they're literally laid out side by side for them to decide what surgery they want.

SPEAKER_04 28:16

Yeah.

SPEAKER_01 28:17

Okay.

SPEAKER_02 28:17

And any more questions that they want to ask you, and they choose.

SPEAKER_04 28:21

Yeah.

SPEAKER_02 28:21

And some people will be like, okay, well let's try bulkamine, it's pretty risk-free. Yeah, it's not as successful, but it might work for me, and that's totally fine. Yeah.

SPEAKER_04 28:29

In a situation like this, how do you strike a balance between, I guess, medical paternalism and informed consent?

SPEAKER_02 28:35

You inform them as much as you can, like you give them all the pros and cons to each. Um, and if they if they can choose whatever they want to choose at the end of the day.

SPEAKER_04 28:44

Yeah. And I think that's a key step in rebuilding trust with patients, isn't that right? And um, you know, moving to informed consent, informed decision making is key. I think gone are the days where you tell somebody this is what you need to do.

SPEAKER_01 29:00

Yeah, this is your surgery, take it or leave it. I don't think that's the case anymore. Where are they available of it? And certainly not in this situation. Yeah, no, absolutely. Absolutely. As somebody like Euro gynecologist who's into sport, what's your opinion on women perimenopause and postmenopause doing like weight training and like kind of high-level resistance training and the effect that some people may say it might have on increasing their abdominal pressure or and then potentially increasing the risk of kind of prolapse and stuff like that. Does that for want of a better phrase, hold any water?

SPEAKER_02 29:37

So I was yeah, and so I was um So I'm the president of the Constance Foundation for another year, and she's Leah Bryan's is the physio. And we were actually talking about it the other day, and she was saying, because I've started doing like weights, which I always hated, and when I rode, I hated them.

SPEAKER_01 29:53

I love weights, I hate cardio.

SPEAKER_02 29:54

I love I love running. But um, and actually when I did the weights and someone showed me how to do it properly, it was weirdly enjoyable. Um, but anyway, so she was like, loads of people will come into me and they're like, I'm not allowed to lift anything anymore after my prolapse surgery or whatever. And I was like, Well, no, that's not the point. Like, you need to build up um your muscle mass because you're losing it with age. And Leah was saying maybe we should, because we have a conference every year, and she was like, Maybe we should talk about with the physios, um, have a physio talk about the importance of weight training after prolapse surgery and how that can really um like build your core and your pelvic floor strength. And it's better long term to be doing like weights, not 50 kilo bench presses. Yeah, but um because I or women.

SPEAKER_01 30:38

Yeah, I worry about women who have continence issues who then get a solution for it, thank God, but then become frail because they're so afraid of going back to that difficult situation with their continence again. So I just feel like there's a cycle that we have to find a way not to perpetuate it.

SPEAKER_02 30:57

Yeah, so I suppose you have to get a good physio before and after your surgery. And like I suppose if you're gonna go to a PT, a personal trainer, to have someone who knows how women work. Yeah, really important.

SPEAKER_04 31:10

Okay, so if a woman is sitting at home and she is leaking when she's laughing, what are the first steps for her to get help?

SPEAKER_01 31:17

Find a less funny husband.

SPEAKER_04 31:19

Okay, number one. Okay, yeah. So how how does one some issue here?

SPEAKER_01 31:24

No, not that one.

SPEAKER_04 31:26

I don't make her I don't make her laugh hard enough to leak, unfortunately. Yeah.

SPEAKER_02 31:30

Um, so go to your GP and then everyone should be on Bajan Leastern, and then so the GP it will tease out what kind of incontinence it is. Um, and like I do GP teaching two, three times a year, and they're really well informed. And even the questions they put into the forum, it's like, Jesus, you know your stuff. Yeah, because like I only know one little organ and little ovaries and stuff, but like they have to know everything. Yeah, yeah.

SPEAKER_01 31:54

GP's a good GP is a good GP is worth a gold, yeah. Seriously, phenomenal, life-changing to be honest.

SPEAKER_02 32:01

Like, I get loads of referrals in, and they've already had the vouch for them, they've already tried the pestry. It's like, oh Brephany, can't like will you help me with that?

SPEAKER_01 32:07

Next step up, yeah.

SPEAKER_02 32:08

Yeah, so GPs are great, and then then ultimately they'll get referred into us.

SPEAKER_04 32:13

Great. Well, Brephany, thank you so much for joining us on the Baby Tribe.

SPEAKER_00 32:17

Thank you. Thanks a million. This show is part of the Headstuff Podcast Network, a hub for the creative and the curious. Shows are produced in association with Headstuff and the Podcast Studios Dublin. Find out more or become a member at Headstuff Podcasts.com.