For that introduction, Lisa, it's great to see you all here. I have no disclosures. So we're going to talk about stress incontinence which is a topic that is probably pretty familiar to most of you. Most people in the room know the basics about stress incontinence. So what I'm going to do today is we're going to talk about the basics briefly, but then I'm just going to go into some patient cases. I know when I was training and learning, like figuring out how to get inside the attending's head and know what they were thinking is what I always really wanted. So I'm going to present a series of cases with different nuances and just talk about what I would be thinking if I saw this patient. So starting off with our first case, a 37-year-old woman who reports leakage with running, lifting her 3-year-old child and jumping on a trampoline. This is a story we've all heard before. And it seems pretty straightforward. But we can't assume that it is. So I'm going to talk now about some of the history and things we're going to gather to understand whether this is really a straightforward situation. So backing up a little bit and thinking about urinary incontinence in general, this is a really impactful condition for our patients. It can have effects on mental health, ability to hold a job and have social connections. If women are fearful for urinary leakage during intercourse, that may limit their sexual function. They may have morbidity like skin changes or ulcers or breakdown because of saturated pads in their underwear. And for some of our older patients who are more debilitated, caregiver burden is a significant issue with urinary incontinence. It's not a small, it impacts a lot of women, up to 60% prevalence. And we're all familiar with these risk factors as we see many of these things in our patients every day in the office. So we all know stress urinary incontinence is involuntary leakage of urine with activities that increase intraabdominal pressure like a cough or a sneeze in the absence of an urge to urinate. And there are different reasons that this can happen. There are two main theories that we think about. One is really a lack of support to the urethra. And this lack of support can come from damage to nerves or muscles or connective tissues at the time of pregnancy, vaginal delivery, or even in women who are doing really high impact exercise, chronic coughing, chronic straining from constipation. All of these things can weaken support tissues or even have a stretching effect on nerves that can impact support to the urethra. Another thing that can happen is called intrinsic sphincteric deficiency or ISD because it's a little easier to say. And this is where the sphincter muscle that encircles the urethra becomes ineffective. And that could also be because of an innervation problem or some other sort of damage. So if you think of the urethra, it's a tube. And that muscle that goes around the urethra helps to close that tube. We call it coaptation where the walls of that tube close down together to kind of almost seal to prevent urine from leaking out. And if that muscle is weakened or damaged and the urethra is a little bit open, or an old terminology we used to say is like a lead pipe urethra just sitting open, leakage can be very severe in those situations. There's not a great standard for diagnosing that condition when you look at the literature. Your patient may have more severe incontinence if that's what's going on, but typically we still have the same set of management options. So we don't need to spend too much time worrying about figuring out exactly what the etiology is. So patient evaluation, I don't think I have to say this in this room, but ask everybody about leakage. So our patients don't totally understand our specialty. They might come in for a bulge and have no idea that we also treat bladder symptoms. So every person you see in your urogyne clinics, you're going to ask everybody about urine leakage, vaginal bulge, bowel symptoms, and sexual function. So you want to ask everybody. And your history is going to focus on understanding her symptoms. When is this happening? How severe is it? Is it one leak once a month when she jumps rope with her kid? Or is this like 10 times a day she's soaking pads, she's wearing diapers? You want to understand the severity, the inciting factors. You also want to look for other warning signs. So things like dysuria, pelvic pain, blood in the urine, those are signs to you that maybe this isn't just straightforward stress incontinence. You also, we said talk about bowel function. You want to ask about medications. Talk to her about her fluids. We do see patients with straightforward stress incontinence, but many of our patients have mixed incontinence, and what they're drinking can really impact their bladder function. You want to understand how it's impacting their quality of life as well. So as you gather all of this history, you're looking for some of these underlying signs that might tell you that there's something else more worrisome going on that this patient isn't so straightforward. And I have those in the box here on the right. So we all know from talking to our patients that most of them didn't just wake up one morning and suddenly have incontinence, right. Usually this starts after a delivery or something else is going on and it's smoldering over time and now they're coming to see us because it's become bothersome. So if your patient says to you, I was perfect until a month ago, that's not usual. You want to gather more information from her. Pain, hematuria, changes in her walking or lower extremity weakness, other cardiac or neurologic symptoms, changes in mental status, recurrent UTIs, if she has an advanced prolapser or an elevated post-fluid residual urine volume, those are all things that you want to think about. This is not just a straightforward situation. So you're going to do a physical exam. So my approach to this is I want to really fully assess her leakage, why it might be happening and is there anything on her exam that I need to address to try and figure out why this is going on for her. So I start just by observing. So when the patient's in lithotomy I just examine, does she have skin changes, is there contact dermatitis from a pad and from moisture? I spread the labia and I look at the urethra. Does it appear normal? Are there masses? Do I see a cyst or any other things going on? I have the patient cough. I want to look visibly, is she leaking? Maybe you want to step to the side as you have her do that cough so that you don't end up with urine. So that's just a tip. We've all been there. But you might want to step to the side or put a hand to shield, but you're going to ask every patient to cough and look for urine coming out of the urethral meatus. We're also going to assess for urethral hypermobility, which that you're going to see if the tissue just inside the vagina right under the urethra moves, right? We've all seen that where the patient coughs and we see the anterior wall of the vagina kind of moving toward us. That's hypermobility suggesting there's some weakened support to the urethra. So I have everyone cough and then I typically move on to a digital exam where I assess the patient's muscles. I palpate them to assess for tone and tenderness. I'll have the patient squeeze to figure out, does she know how to engage these muscles? When I ask her to squeeze, does she lift her bottom off the bed? Does she bear down or is she able to give a good squeeze? I do just a very basic neurologic assessment of checking for sensation on the bilateral labia majora and asking her if she feels it equally on both sides. Most of our patients aren't going to have a neurologic problem causing their urinary leakage, but that's a way just to do a simple neurologic exam. And then while I'm doing that by manual, as I'm completing it, I typically turn my palm up and I palpate underneath the urethra. Some of our patients who present with stress incontinence will have a urethral diverticulum and we don't want to miss that. Those are patients that we especially don't want to put a mesh sling in, so we wouldn't want to miss that. So for those patients, you're going to just palpate under the urethra, pulling your finger towards yourself and looking at the meatus. Is there discharge coming out of the urethra when I palpate the urethra? And then I do a speculum exam to look at the health of her vaginal epithelium and to look for any urine pooling in the vagina. Most of our patients won't have fistula, but that would be a warning sign for that. You don't need a lot of further testing for stress incontinence. These patients should have a urine analysis and then you can send it on for culture or microscopy depending on your findings. You should do a cough stress test and all of them that I just described. Your patient in lithotomy, especially if she's voided at the start of the appointment, may have a negative cough stress test. And that doesn't mean she doesn't have stress incontinence, it just might mean that she's laying down with an empty bladder and she's not going to leak in that situation. So if you want a bladder test, cough test that's going to be more useful, make sure that there's fluid in her bladder. And this is shown to be really useful if there's at least 300 milliliters in the bladder. Checking a post-void residual is not required for initial therapy. Before surgical interventions it should be evaluated, but if you're going to send your patient for low-risk, non-invasive therapies, you don't have to have a PVR. There's really no role for urodynamics in the initial evaluation of stress incontinence. So to talk a little bit more about urodynamics, what are some situations where you would think about getting urodynamics? So these are really more complex patients. People who've already had incontinence surgery, who've had pelvic radiation, they have a neurologic diagnosis. And then anything that caused the diagnosis into question, something that's just not quite adding up. Like she complains of stress incontinence but has a lot of nocturia. That's a little bit unusual. If her PVR is elevated, or say you do that cough leak test in the office and she doesn't leak until about three or five seconds later her whole bladder pours out, that's a little bit unusual. So that's a situation where you also may want to do urodynamics. So coming back to our case, so she's 37 and she leaks with physical activity. We talked to her a little bit more. She's got no urgency or urge leaks and no nocturia. We did her exam, her sensation is normal, her vaginal epithelium is normal, her urethra is hypermobile and she does have a positive cough stress test. Pelvic floor muscles are weak, her UA is negative and her PVR is normal. So she's pretty straightforward so far. So now what are we going to do next? So we're going to start with some patient education. So every patient I talk to them about what were my exam findings? Is there anything on your exam that might explain your leakage? And then I go on to talk about their diagnosis based on the information that I've gathered from seeing her. And I think Jen talked briefly about Ogg's patient handouts. Ogg's has some really great patient education tools. And so they have this handout on stress incontinence. Many of our patients will have questions and want more information than we can convey in our appointment or they'll go home and think of questions. If you send them with some educational materials that can be really useful. They might be overwhelmed at the appointment and not really be able to take the information in. And this is a way to give them information that they can read at home. One of the things I emphasize to patients is that stress incontinence is not life threatening. So I want her to know that she doesn't have to treat this if it's not bothersome to her. I should understand if it's bothersome at this point because I've interviewed her and asked her a lot of questions. So I remind them that they don't have to treat this if they don't want treatment. Another thing that we talk about sometimes is weight loss. So for women who have stress incontinence, we know from randomized studies that weight loss up to or at least 8% of body weight can lead to improvements. Especially for our obese or overweight patients, this is something to bring up. Vaginal estrogen in general helps the health of vaginal and bladder tissues. So if she has severe atrophy, you may want to consider giving vaginal estrogen. Different providers approach this differently. Some people feel like every postmenopausal woman should get vaginal estrogen. I'm probably not that aggressive personally. I discuss it with patients. We talk about whether or not they're symptomatic. Because our patients often are given multiple interventions to carry out. And if she's not symptomatic from atrophy, sometimes I don't always prescribe it. Because sometimes patients feel like they're then not complying with our recommendations when really maybe the estrogen isn't going to help her feel better. So you want to have a little bit more thoughtful conversation with your patients about estrogen, why you're using it, whether or not it's necessary for her, rather than just telling her to use it. If she forgets and she's not symptomatic from it, she may then have some negative feelings about her ability to comply or feel like she's not doing a good job with her health when maybe it's not the most important thing for her. So you want to prioritize these things and think about what works for your patient. And then we'll talk, I have some slides, we'll talk about these other things. Okay. So pelvic floor exercises, it takes time. So these exercises can be really helpful for patients, but it takes time. We know from the literature that it can take up to six months to see the full effects of pelvic floor exercises for urinary leakage. And that's okay. But our patients need to understand that when we tell them about this therapy. One of the things that you're going to do during your assessment we said is assess their pelvic floor ability to contract and their strength. A woman who can do a good strong Kegel for you may not need supervised pelvic floor physical therapy. She can do a good strong squeeze. She just needs education about how to practice her exercises and to pair it with activities that make her leak. Our pelvic floor physical therapy colleagues are amazing, but they're a limited resource. And so we want to be thoughtful about how we utilize their time just like we do with any resource. Also patients have to go to the appointments, it can be costly. So if there's a woman who is motivated and able to squeeze her muscles, that may be a situation where you can use one of the OGG's handouts and have the patient do some practice on her own at home to try and make her symptoms better. I'm not going to go deeply into this because we're going to have a great pelvic floor physical therapy talk and we have our workshop over the weekend. But I also emphasize to patients that the relax is important too, right. Our muscles aren't meant to only squeeze. They also need to relax between contractions. So we can teach her to do this on her own at home. If a woman cannot even flicker her muscles in the office and is doing Valsalva when you ask her to squeeze, she probably is not going to be successful on her own at home doing Kegel exercises. She needs education for that. So you want to be careful about telling those patients to just go home and do Kegels. In addition to the pelvic floor exercises, we can do other things to enhance it. Supervised pelvic floor physical therapy with or without biofeedback. There is some in the literature about weighted cones. I don't typically use this for my patients. I will let some of the physical therapists in the audience comment on their thoughts about that. I don't typically recommend it. There are digital therapeutic devices we can use that patients can insert in the vagina to give them feedback about whether or not they're doing exercises properly. And there's some mobile applications as well. So pessaries can be useful for stress incontinence. And patient satisfaction is documented to be up to 50% at one year. So when we counsel patients about pessary for incontinence, we don't really know if it's going to be effective for her, but we can talk to her about that option. I think this can be really helpful for patients who have really specific leakage. So I've used this really successfully in patients who say, tell me, I only leak when I run. That's the only time I leak. It really bothers me then. I'm not ready for surgery, perhaps a pessary only when she's running might be a great solution for this patient. Do you really want to kind of listen to her and see what her symptoms are when they're bothering her to help you understand how to tailor treatment for her? So moving on to some surgical procedures. Urethral bulking is one that I'm sure people are familiar with. This can be performed in the office or the operating room. I think the injection that people are doing most commonly now occurs in four quadrants of the urethra, and I personally feel like that's much easier to do a good job with those four injections in the operating room, but that's how I do this. But essentially, we look inside the urethra, place a needle where we inject a medication or a filler around the urethra, which you can see in the blue in the picture here, to help the urethra close better, to increase resistance to urine leakage. The great things about this are that it's minimally invasive, right? If you do this in the OR, the patient wakes up and goes home with no restrictions. The risk of urinary retention and voiding dysfunction is very low. There are very low risk of complications. That makes it really nice. Doesn't work as well, though, and doesn't have as good of longevity as sling. So this is nice for a patient who, say, maybe medically isn't healthy enough to have a bigger surgery, or who doesn't have time for any post-operative restrictions right now, and so maybe she wants to do this to kind of get her to a different time in life. It's also important for patients to know if they do this, it doesn't mean they can't have a sling in the future. So this takes nothing off the table for the future if they choose to have this therapy. We're all familiar with slings, which can be retropubic or trans-obturator. We also have mini slings or single-incision slings. I just don't have a picture here. This is performed in the operating room with very high satisfaction rates. So this is really our chance to get the patient's highest chance of being dry with the lowest risk of complications. Dry rate is about 85% after the procedure with satisfaction even higher than that. Does come with surgical risks, risk-avoiding dysfunction, retention, and mesh erosion or exposure. So thankfully, those things are uncommon. This is considered a very low-risk intervention. It's just higher risk than bulking. So preoperative evaluation for midurethral sling does not require urodynamics, especially if it's straightforward stress incontinence or stress-predominant mixed incontinence. We have a nice randomized trial from a little over 10 years ago that compared urodynamics to a basic office evaluation before undergoing a sling, and they found no improved outcomes in women who underwent urodynamics. But what they required for the office evaluation was that every woman had a positive cough stress test, a negative UA, a normal PVR, no significant prolapse past the hymen, urethral hypermobility, and that they either had pure stress incontinence or stress-predominant mixed incontinence. So not all of our patients will fit into this, but we have good evidence to tell us we don't have to do urodynamics on everyone. We should really do it when we have a clinical question or it may impact our management. So coming back to our patient, we'll talk about her and then we're just gonna go through a series of other patients to talk about how I think about some of the different ways and things that people can present with. So we recall that our patient was 37 and she's leaking when she's active with her child. She has no urgency or urge leaks, no nocturia. Her exam is normal except for some pelvic floor weakness. So she's uncomplicated stress incontinence. So most of the treatment options that we have are available to this patient. We could talk to her about exercises and she has some muscle weakness. The most important thing I think here though is her age. She has a young child. She may have more children. And if she has a sling and chooses to have more children, we don't have great guidelines or data about how to deliver subsequent pregnancies and we don't know a lot about outcomes. So she's trying to become pregnant now. You may not want to recommend a sling urgently. We also have to think about post-op restrictions. She has a three-year-old. She's probably picking that child up multiple times per day and they probably weigh more than 30 pounds. And so we have to think about whether or not post-operative restrictions are feasible for this patient. I'm gonna keep going through some cases. If you have questions, comments at any point, please, we have some microphones here. Please raise your hand. I'm happy to provide further information. So our second case is a 52-year-old who reports urine leakage with cough and sneeze and her BMI is 47. She has nocturia once a night in very rare urgency. On your exam, normal sensation, normal epithelium, no masses, but she cannot contract her pelvic floor even with your instruction. You're trying to do some coaching with her and she just can't do it. So she's got uncomplicated stress incontinence and inability to contract her pelvic floor. So again, most of our treatment options are available to this patient and reasonable, but in a patient who can't contract her pelvic floor at all, I really talk to her about that exam finding and why pelvic floor physical therapy may be a good idea as a starting place for her. Talk to her about weight loss with a BMI of 47. Bulking and sling aren't wrong for this patient, but we wanna think about our patients holistically and let them know the findings of their exam. And so I always wanna talk to patients about the option of physical therapy, especially if they can't engage their pelvic floor muscles. So this is a 66-year-old patient who has urine leakage with cough and sneeze and her BMI is 27. She also has urinary urgency, frequency, nocturia, twice a night, and dyspareunia. On her exam, normal sensation, atrophy's mild, but her pelvic floor has significantly increased tone. It's tender to palpation. She can't squeeze because her muscles are so tight already she can't relax. So her SUI is not technically complicated, but she's got pretty severe pelvic floor dysfunction. So again, you wanna have another careful discussion with the patient about your exam findings. Here, I really want this patient to understand that pelvic floor dysfunction makes it really difficult for the bladder to function properly, to know when it's full, when it's empty, to be able to relax to pass urine, to squeeze at the time of increased intra-abdominal pressure. If her muscles are completely in spasm, she can't have a reflex contraction of the pelvic floor at the time of increased intra-abdominal pressure, like a cough or a sneeze. So we want to go over all those things with her, let her know this probably is related to her dyspareunia as well, and she probably has some bowel symptoms too that came up during our interview. And so these patients, I'm generally pretty reluctant to offer them other therapies other than physical therapy. And this type of patient, placing a pessary is gonna be really painful. If just my one finger on exam hurts, she's probably not gonna feel great with a pessary sitting in the vagina on those tight, tender muscles for hours a day. And I typically don't wanna do surgery on these patients. They're already in pain, and so if I add more pain to that through a surgery, I could potentially make her worse and I may not fix her leakage. So next case, we have a 67-year-old with severe urine leakage with all movement. She says, she's one of these patients that she just tells you, I just leak. Like, I look to the right and I leak. Everything makes me leak, right? She had a sling five years ago, but it was removed three years ago because she had pain, it got exposed in the vagina, so she had it removed. She has no urgency. She has nocturia once per night. On her exam, she's got normal sensation, vaginal atrophy, and pelvic floor weakness because most people have pelvic floor weakness. So she's complicated now, right? She's not our straightforward patient anymore because of her history. So you definitely want a PVR on this patient. We said earlier, you don't have to have a PVR in straightforward patients to do initial management, but this patient, you definitely want a PVR because she had a sling and it was excised. She could have scarring around her urethra causing incomplete bladder emptying. Maybe she's full all the time and small movements cause leakage because her bladder is always full. So you really want a PVR in this patient. Maybe UDS, depending what you find on your PVR. You could consider pelvic floor physical therapy or a vaginal insert, but her leakage is really bad. She probably doesn't want a vaginal insert. She probably wants something more definitive. So in this type of patient, maybe a fascial sling made out of the patient's own tissue or bulking might be appropriate, but you don't want to put mesh in her again because she's already had one mesh complication. So she's not a good candidate to get more mesh. Now, the way I talk about this and her potential treatment options are based on my practice, my skillset, what I think is the right thing to do. This kind of patient is one that you definitely want to discuss with your collaborating surgeon, right? You don't want to offer fascial slings to patients if your collaborating physician doesn't do fascial slings. So a lot of these kinds of things, when you start thinking about surgical interventions with a patient, you want to know your collaborating surgeon really well. And I'm going to talk about this a little bit more this afternoon about prolapse surgeries, but get to know your collaborating physician, understand what they think about certain conditions, especially surgically, because the patients are going to ask you what they're going to recommend and you want to be able to say something that's going to have something to do with what they're actually going to offer the patient. So the next patient is a 45-year-old who has urine leakage with cough, sneeze, and she has some dyspareunia. She's got urgency and recurrent UTIs. So you're a little suspicious about these UTIs. On her exam, she's got normal sensation, normal pelvic floor strength, but at the end of your bimanual, when you palpate her urethra, when you're removing your finger from her vagina, there's a little fullness under her urethra. When you touch there, she says, well, that didn't feel so good. I don't know what you just touched, but that was uncomfortable. And you're looking at the meatus when you do that because urethral diverticulum is part of your routine assessment for incontinence. And you see this yellow discharge coming from the urethral meatus when you do that. So she's complex for sure, and you're worried about her urethral diverticulum, right? She's tender, she's got recurrent UTIs, and you see discharge from the meatus. So again, you definitely want a PVR. She's complicated. And you have to evaluate the diverticulum first. We don't place mesh on a diverticulum, and so we wouldn't want to miss something like this. This is why you're always gonna evaluate the urethra. So now you have to evaluate this diverticulum to figure out, does she actually have a diverticulum? That's an important thing you want to know before treating her stress incontinence. So there's some different ways to do that, and this is, again, when you want to know your collaborating surgeon. Some people always do cystoscopy in the office for these patients, looking for a connection from the diverticulum into the urethra. That's not always definitive. It may show us that there's a diverticular opening in the urethra, but it doesn't tell me how big the diverticulum is. Is it going all the way around the urethra? Are there multiple diverticula? So usually there is a desire for imaging before you do a surgery on a patient with a diverticulum. This can be done with MRI or ultrasound. Ultrasound, like anywhere else in the body, is very operator-dependent. So I've definitely had a situation where I ordered an ultrasound for a diverticulum, and they didn't even image the urethra. So not helpful, right? It's also the patient has just had a probe in her vagina, and now we have no further information about what's going on. So you want to understand the resources at your institution when you order this testing. If your institution has dedicated GYN physician ultrasonographers, go to that person, have a conversation with them. Can you image the urethra for me? If you're just sending her to radiology, you're probably not gonna get an answer. So you wanna really understand the circumstances of this ultrasound before you send her for it. I would say that most people consider MRI the gold standard for evaluating a diverticulum, and that you want a pelvic ultrasound without contrast for that. That's really our best test. It can be costly. Sometimes insurance doesn't wanna pay for it, or it's very costly to the patient. So if I want the MRI, but I can't have it for some reason, you could do the ultrasound and talk to your radiologist or the tech and try and get a good ultrasound. In the situations where the ultrasound's not helpful, then often I find that insurance will then pay for the MRI. But I typically in my practice go to the MRI first, given my limited success with ultrasound, to try and save the patient from multiple appointments. So the last case, next to last case, is a 48-year-old with leakage with cough, sneeze, and a sensation of a vaginal bulge. You exam her, her sensation's normal. She has stage three pelvic organ prolapse, a positive cough stress test, and a PVR of 200. You measured her PVR because she has advanced prolapse, so you decided that that was necessary in her initial stress incontinence evaluation. So she's complicated because she has incontinence, prolapse, and an elevated PVR. So you have to kind of discuss all these things together. Even if the patient came in just complaining of leakage and you think her prolapse is significant enough that it's impacting her ability to empty her bladder, we can't really just talk about her stress incontinence. You have to talk to her about everything that's going on. You're gonna always talk to patients about everything you see on their exam. And so you're gonna explain the prolapse to her as well, probably using a nice Oggs education handout. So this patient has some different options. She could try a pessary. A vaginal insert probably isn't gonna work for someone with stage three prolapse. It's probably gonna fall out. You could try a pessary and then reassess her PVR and leakage. If she elects for surgery, this is a patient who I think most physicians would do urodynamics on because she has advanced prolapse, leakage, and an elevated PVR. So you want a little more information going into that surgery. But this, I think, is where it comes to be really important to understand why patients are coming to us and then to do a comprehensive explanation of exam findings for every patient because it helps them understand why maybe she came with leakage. This bulge doesn't bother her, but you really wanna talk about this bulge. So we want patients to really understand that all of these things are interrelated. So our last case is a 58-year-old who has urine leakage with cough, sneeze, and urgency. She's got frequency. She's getting up three per night to go to the bathroom. On her exam, she's got normal sensation and pelvic floor weakness. So she has mixed incontinence. So in these patients, I typically get a PVR on them. We don't need urodynamics straightaway. It's rare that we need urodynamics straightaway other than in some of those situations I talked about early on. So this is then where we have a conversation with the patient about what's bothering her the most to try and sort out where we should begin. And one thing that I think sometimes patients appreciate is that pelvic floor physical therapy can help with multiple types of leakage. So sometimes if they're a little leery of the therapy, I can explain to them that this could help everything that you're dealing with. These patients also commonly might have constipation. And so you can talk to her a little bit about all of the things that physical therapy can help with. So that's a good option for her. If she's not interested in that, or if she wants to do that and something else, it's okay to pair medications and physical therapy. We also might start with a bladder diary in a patient like this to understand how her fluid intake is impacting her function. So I was hoping we would have a minute for questions and discussion, but I see my timer is up. Do we have any time, or am I finished? So to repeat the question for everyone in the room and online, the question is are we having any trouble getting surgery paid for without urodynamics preoperatively, specifically for sling? I have not had that experience. I know one of my colleagues has had that sometimes when it comes to advanced therapies for overactive bladder and urge incontinence. I haven't had that experience. But I make sure in every chart I have that comprehensive office evaluation documented with PVR and all of that. So it may be documentation, but the landscape is constantly changing of trying to keep up with what we have to document for insurance companies. Yeah, so weight loss, it's really hard. My approach varies with every patient. Some patients, especially who you can see are medically complex, who maybe have limited – like a woman who can't walk around except using her walker, I'm probably not going to have a really long conversation with her about weight loss. So part of it is assessing like patient motivation, lifestyle. Sometimes I will bring it up and just say like, studies have shown that weight loss can be helpful for this. And sometimes I just put that there and see what they say. They might ask more questions or they might say, okay, but I really want this fixed right now. And so I try and just see how the patient reacts, but it's hard, right? Because most of our patients who are obese or overweight have already been told many times. And so I try and be careful not to make women feel like you just have to go lose weight and you'll be fine, right? I don't want to dismiss them. So it's hard. Yeah, so I think it can be helpful, but I'm definitely not an expert in it. So typically patients who I think may need e-STEM to help get their muscles going are patients that I'm typically really encouraging to go to pelvic floor physical therapy. And usually if I really take time to explain their exam to them and the difference between squeezing and contracting and how that impacts what's happening with their bladder, usually they're amenable to it. But I'm not necessarily like implementing e-STEM myself. We'll do one more question, and then if anyone has questions, write it in the chat box, and we'll put it in that final document for her to answer after the course. Dr. Probst, how would you evaluate the patient's mechanism of voiding if you're going to be taking her to the operating room for a sling, but not necessarily doing aerodynamics? So what the value study did was they used PVR to assess voiding. So we don't currently have any evidence that assessing their mechanics of voiding is necessary before the sling. So I think what the ValueTri really taught us is that for a woman who doesn't give us complex symptoms, who has a normal PVR, her voiding is probably normal. Thank you all.

stress urinary incontinence

patient evaluation

treatment options

pelvic floor exercises

urethral bulking

interdisciplinary approaches

mental health impact