Alexander A. Berger, MD, MPH, FACOG, a specialist in female pelvic medicine, offers a guide to discussing, diagnosing and relieving frequently seen disorders that profoundly impact quality of life. From incontinence to organ prolapse to recurrent infections, these conditions have many treatment options to suit individual needs. Bonus: Tips on distinguishing types of urinary incontinence and an important caveat on use of anticholinergics.
mm. So let's get started. Um So we'll talk today about public for disorders and recurrent U. T. I. S. Um When we talk about public for disorders and female public medicine and reconstructive surgery it's a fairly new field actually became aborted subspecialty within O. B. G. Y. N. Just about seven or eight years ago. And so most people aren't familiar with the common term that was used before as Euro gynecology. And so I wanted to start by just talking a little bit about what kind of conditions do we treat in our field and some things that you might see and how we can approach them. Um So here's some representations of things that we treat. We see an example of maybe somebody with pelvic organ prolapse. Here's somebody jumping on a trampoline, leaking urine. So stress urinary incontinence. There's somebody maybe with some urgency to go to the bathroom and they can't make it to the toilet in time they're running. And they have some leakage on the way there. Somebody with pain or over activity in their bladder, somebody with pain in their pelvis, somebody with pain or discomfort with their bowels, somebody who's pregnant and has some conditions related to that. Somebody who has infections, urinary tract infections or recurrent urinary tract infections and then somebody who has a blood in their urine material. So as we talk about these pelvic floor disorders will kind of highlight a little bit about the path of physiology and treatments. And I'll take some breaks to kind of workshop questions as we know that we have the first one we'll talk about here are prolapse stress, incontinence, urgency and comments later spasm and then I'll end with recurrent U. T. S. So talk a little bit about some of the things that we do at UCSF related to my research and innovative therapies um that I think offer a great opportunity to collaborate and take care of patients. So let's talk a little bit about pelvic floor disorders first, so many people aren't familiar with this concept, but it's the different conditions that I mentioned a moment ago and what we see here is the the prevalence or how often these things are different ages. So you can see here very quickly that things like urinary incontinence, leakage of urine, Um it's much more common as we all get older. So you can see her in young patients, the 20-39 year old, it's pretty uncommon. But as patients get older, as we see here in this picture becomes much more common than in fact, as people get older, especially in our very elderly population or geriatric population, but also population that lives in assisted living or other conditions. It's very kind. So prolapse prolapse, which is a hernia of the pelvic organs through the pelvis. Symptomatic collapses is thankfully not as common as incontinence, but you can see here becomes more common as patients get old people in common. So fecal incontinence is the loss of stool outside of somebody's control. That also gets much more common. As patients get older patients who are in institutions, it is unfortunately way too common. So overall, if you survey patients, the likelihood of a public floor disorder goes from 10 in the younger populations, about half of all patients by the time they're 18 months. So it's really common. So this emphasizes the importance of um asking about these symptoms, screening in all settings and um general practices, family practices. Geriatric internal medicine practice is really important to be aware of the frequency of these symptoms and also importantly recognize that these symptoms are the hardest things to talk to your doctor about, your nurse practitioner or your um physician assistant or whoever is caring for you. These are symptoms no one really wants to tell somebody else about. They're not gonna tell friends, family. So really difficult to share with their providers. So definitely something worth being aware of frequency and asking questions. One of the myths that we know is that white heard white women have by far more higher incidence of help for disorders. We actually know that there's no differences in race midst of your comments. And so in our community, very diverse community. We see that there's pretty similar rates across races and backgrounds. Um, and our diverse community, we should feel comfortable and aware that they are very common across the patients. So, given the frequency of these, given how it's very difficult for patients to talk about these issues, um, it's likely that we're not reaching and identifying these problems and also importantly, patients just don't know that there's something they can do about it. That's a majority of the patients that come see me in the office, say when they come meet me, I didn't even know there was someone like you out there that they can take care of this issue. I didn't even know there was treatment. Um and my friends didn't know. So really an emphasis that there's a lot that we need to do in terms of outreach and I'll talk a little bit about that leader. So let's talk about how bothersome public floor disorders are. We did some studies screening for these different syndromes and and looking at how bothers some of these things are. And as we look through here, you can see at 100 100 score 100 or percentages that someone felt that the symptom was better than death, somewhat better than death. A little bit better than death. Not better then, worse than death. And as we look through here, when you ask patients about bowel and bladder and contents, meaning that they lose urine or feces outside their control, more than half of patients said having those symptoms felt worse than death, meaning that it was so bothersome, it was that affecting to their quality of life. And as you look through here, there's other things that people get assessed for being in a wheelchair, not being able to get out of bed, other sort of quality of life things, and in fact, those are often rated as either less bothersome than content. So this is an emphasis that people having incontinence. This is very bothersome. It incredibly affects their quality of life and really makes life so difficult for our patients. And we'll talk about that a little bit more as we could. So this kind of emphasises some of those issues as we kind of go through. I want to talk a little bit about pelvic organ prolapse and and how these things are caused. So pelvic organ prolapse. Again, we're looking here at a mid satchel view from somebody cut in half, and we're looking from the side, this is the front of the body here, the pubic bone, This is the urethra, bladder, vagina, uterus anus rectum and then the spine back here. And as we look here, we start to see some of those anatomy points. And when you see prolapse, it's a hernia of these organs pushing out overwhelming or having poor public for support our muscles and tendons holding things inside. They no longer working through disorders or problems related to childbirth injuries, aging, other disorders. And they start to come out just like an abdominal and delightful hernia inguinal hernia. Same concept. But this is the pellet, everything starts to fall out. So let's talk a little bit about some of the problems that happen as we treat these things that you may see in your practice when you do a vaginal exam or have patients that have had surgery, we know that more and more. We're seeing patients that are having mesh surgeries. And occasionally when you look at a speculum exam, you may see something like this, this mess exposure. So it's important to be aware that that's something that you can see in your community. And certainly I see patients that come in or refer to in because a mesh surgery they had done has a complication and we'll talk throughout today that mesh complications thankfully are rare and much rare now with our new techniques and new mesh, but occasionally you may have a patients say I'm having some vaginal bleeding. I'm noticing something I'm through. I had this procedure for collapse, what's going on and you may see this and this is something important to refer for. And as we kind of look at this, there's many factors that are causing this. People having an infection, people having a reaction inflammation, other things that are going on that are important to be aware of because we kind of looked through this. So let's give an example of a patient with pelvic organ prolapse. So the typical presentation will be a patient generally older, but it can be younger. I see patients in their twenties and thirties as well. But common patients 60 seventies, this patient 72 they tell you that every time they walk around or sit down they notice a bulge, it feels like there's a balloon that they're sitting on their sitting on a grapefruit. They're sitting on a tennis ball. Often my patients died a patient today who's a skier and she said, I can't go skiing. As I noticed this bulge, it makes it uncomfortable, I feel it in between my legs. I can't leave my house. So some of the questions that we want to think about or what questions should we ask this patient? What past medical history should we address? How do we diagnose it? How do we treat it? So some of the questions that we should ask for things like what are your symptoms? How bothersome market them? Are you feeling pressure? Are you feeling something coming outside? When do you notice it? Have you tried any treatment for it? Have you noticed any bleeding? Have you noticed any pain? Those are some of the things that we should kind of assess as we go through that and also ask about other pelvic floor disorders, like incontinence. That we'll talk about a little bit relevant past medical history is things like their prior surgeries. Did they ever have any treatment for the surgeries? Other things like that? Other surgeries in their life into abdominal surgery is important to understand because maybe they have previous surgery to their uterus hysterectomy. Perhaps other medical history that's really important is connective tissue disorders. Things like those. Damn most. You make this much more common. Other things are obesity, increased intra abdominal pressure because of obesity can make this way more common as well. Um, medications that patients are on smoking, other things that are important, You know, typical history. How do we diagnosis and treat this? I'm going to get into that next and I'll show some pictures here. So this is that mid satchel view again. And I'm just going to talk about some of the types of prolapse. Um and these are some of the things that we'll see and you may see in your practice as you need patients. So, this top picture here is normal anatomy is similar to the picture I showed before. This top right picture is an example of assistance seal. Another term used for that is anterior wall prolapse for bladder prolapse. And as you can see here, this is that bladder that's pushing out like a hernia, pushing the anterior vaginal wall and it's pushing it to the opening of the vagina and sometimes even outside. So, if you do vaginal exams for a patient and you're looking inside, you'll see that front wall with vagina pushing out. That's what we're seeing with that sister seal. Direct to seal this bottom left here. The rectal seal term or post your wall prolapse is the rectum pushing out into that poster wall. The vagina pushing out into the vagina and pushing down and lastly, is the typical for uterine prolapse of the patient as a uterus. It's uterine prolapse, that's the uterus coming down. If the patient doesn't have a uterus, they can still have prolapse and it's called vault Prolapse of the uterus is an innocent bystander here. It can be present or not present. Doesn't matter. Patient can still have prolapse. And we see that here. So we diagnose this with an exam. So in your practice or if your patients are fertile practice, we would do a vaginal exam and then we take some measurements of the different components of the prolapse and be able to show the patient what type of prolapse that they have. And then talk about treatment options. So next to the treatment options, patients always have an option of expectant management or doing nothing. And I always emphasize that with patients that this is really their choice. The choice of how they want to perceive is all up to them thankfully. This, along with most of the things I'll talk about today are not dangerous conditions. They're not going to kill the patient. They're not like a heart attack or cancer stroke where surgery is necessary. This is elective, it's their choice. And so they can always decide to do nothing and expectantly management if a patient has prolapsed and they don't notice it. I always say if you don't, if you're not bothered by your prolapse, I'm not bothered by your prolapse. So just because the patient has it, if they don't notice it, it doesn't cause any symptoms. We do not have to treat it. But for a patient that does have bothersome prolapse and wants treatment. The first considerations are conservative, nonsurgical management. So we see here in the top left are examples of pets Reeves. Some of you may place pastries in your practice or see them or have patients that come through that happened. Pastries are braces. So the analogy I like to give, it's like if a patient had knee pain and they could get a brace place for their knee where they could have knee surgery. This is the example of the brace. It doesn't treat the prolapse, it doesn't prevent it. Long term, it's a brace to support the prolapse and as a temporizing measure, um, some patients can live with this for the rest of their life. Um, Some patients will use it temporarily. My patient earlier today is a skier was saying that she would probably use a pastor just when she sees or she runs or hikes and other times other than that won't use it similar to knee brace. You may just place it for your activities and taken off afterwards. So this is an option for patients. We have a group of people, including myself and my nurse practitioner, my office that can place them. Um, and it's something that we can help manage and collaborate with your offices or others to help maintain them as necessary. Other options are surgery and now you see here an example of one of the robotic mesh augmented repairs called the secret cotopaxi that perform. I have both mesh augmented and made of tissue pairs. Mess should be just like a abdominal hernia repair from general surgeon to be a mesh augment or structures. So this is the example of that mesh augmented, repair more durable but with additional risks. Some of the ones I talked about earlier. There's also an option of native tissue which is using the patient's own ligaments and futures. And that's a reasonable option with a higher failure rate but potentially less risk. And as was mentioned in the introduction, I do surgeries where moved the uterus, where keep the uterus depending on the patient and their desires related to that. I have range of options depending on the patient and the way they want their condition treated thankfully all the options are minimally invasive, with rare exception, minimally invasive patients having small incisions going home the same day, recovering within two or three days to most function at home and within a week most of most activities outside the home. So really in general are average patient has a really minimally invasive quick recovery from surgery and does really well. The next couple are about incontinence, stress, incontinence, that this is an example of a patient. She's 38, she's urinary incontinence. She trampolines with her five year old daughter and leaks urine every time. A patient just a few hours ago that I met for the first time said that when she did Zuma before Covid, she would leak every class and would be very embarrassed by this. This is common coughing sneezing, laughing. I've had patients that are olympic weightlifters and they leak every time they lift the heavy weights over their head. This is caused by an increase in intra abdominal pressure patient coughing, sneezing, laughing, increased pressure on their pelvis and the Aretha not being able to maintain your inside man. And we'll talk about that in a moment. So what questions do we ask? When does this happen? What causes it? How long has it been going on? Any treatment that the patient's tribe? A few other things that will go through in a moment relevant past medical history, particular here is obstetrics history just like with prolapse large babies public for injuries, lacerations, um obstetrical trauma, um smoking. Anything that caused the patient cost like COPD um obesity. Those are some of the important ones as well as surgical history and things along those lines. Uh dietary habits, particularly drinking and those types of things become important as well, how to diagnose it and treat it. We'll talk about that here. So tres unconscious is a loss of support around the urethra. And we see that example here where there's some ligaments between the pubic bone and the bladder and vagina that support that and those are damaged to childbirth injury and aging. And so over time, the muscles and support here gets weakened. And the theory here is that with strong support when a patient coughs sneezes and laughs, that urethra is clamped down and there's no urine that comes out and with weakened support with aging and childbirth injury, there's leakage that occurs. So what can we do for treatment? We can increase the support with public for physical therapy history, surgery. We can both around the sphincter. And there's lots of opportunities in the future, including a study that came out just this earlier this week from Cleveland clinic. We're working on immune modulation and stem cells and a lot of things that are really exciting down the line. So here's some pictures that represent that. Here's a pizzeria being placed for this little knob. If you ever see patients come in with that knob, or if you place these, that knob is meant to sit underneath the Aretha on the anti wall to support that urethra. And here's an example of a retro pubic midriff or sling. It's the The most common surgery that we do for this condition, a small ribbon of mesh that goes underneath the urethra surgery that takes us about 15 minutes. The patient goes home the same day. Um we do 250,000 of these surgeries in the United States every year. I do about 150 to 200 every year. So our gold standard treatment for stressing contents within 85-90 success rate. So I move forward here just to urgency and continents and then hopefully all the time for a break after that. So to distinguish urgency and contents from stress and constant stress incontinence. Is that coughing sneezing, laughing and continents. It's caused by issues with the urethra, Urgency content is a little bit different. So let's tell you about a patient and then I'll talk to you about the cost. So urgency contents may be a little bit of an older patient often 67. In this case they can't get to the bathroom in time rushing have an urge. I can't get highly, patients often say to me, I can't back before covid, I can't go to the mall. I can't go shopping. I can't get together my friends to play bridge or go for a walk because I constantly have to find a bathroom. In fact, during this arab covid with the lack of public available restrooms, we're finding more and more of our patients are saying when I'm out and about, I can't do anything. I literally can't leave the house because I don't know where the next bathroom. This is really a major issue for our patients. So relevant questions. A lot of the same ones we asked before here, it's caffeine are using caffeine stimulants that may stimulate the bladder fluid intake. How much are you drinking? How much you're peeling. Some patients may have diabetes, insipid diabetes in general. That may be related to fluid issues relevant past medical history. A lot of the stuff we talked about before but certainly hypertension, diuretic use other things like that. And then let's talk about how we diagnose and treat it. So this is overactive bladder which is a synonym for urgency and continents. It's that urgency to get to the bathroom frequency. Often associate with getting up at night to pee. Um no uTI. Or other costs. So the issue here is a disconnect between the brain and the bladder coordinated function between the brain and bladder keeps us all continent in the absence of that because of aging, childbirth injury. Often neurologic conditions like M. S. Or multiple or uh spine injury or even back pain or herniated disc can lead to things like this. So lots of issues here. But you always want to rule out by getting a urine sample um doing a urine culture just to make sure that there's not a urinary tract infection. And that's really important to rule out. So treatment options here, behavioral therapies are first line so that's flattery training, timed voiding, pelvic floor physical therapy, second line or medications. Anti coal energy mix and beta three agonists which is near veteran. I'll caution everybody with antique all insurgents. We used to give these a lot. We knew about the dry mouth, dry eyes, constipation, What we're seeing now. And some really big retrospective studies counseling a big association with dementia with anti culinary. So I have not prescribed in 206 months. Um and I really caution my colleagues here on this webinar to consider um other options than anti Colin urgency, given that concern about cognitive decline and dementia. Beta three agonists or mayor metric are another medication that's used similar, effective with a potential risk of increased blood pressure. So important to track blood pressure and avoid starting this in an uncontrolled hypertensive patients. Lastly, there's procedures like Botox, a former modulation and post tibial, posterior tibial nerve stimulation, which is acupuncture, which I'll talk about a little bit here. Next. So here's some pictures to represent that we're seeing here. An example of bladder Botox. I do this in my office, the patient's awake, we numb the bladder with topical lidocaine. I use a small sister scope to look inside the bladder. And then with a small needle I inject Botox into the bladder. A very effective treatment with some risks urinary retention and recurrent ups can be more common. So we talk to patients about that and counsel them. And they have to be willing to in rare cases have to be able to catalyze, be able to do that. So not great for our patients with limited dexterity where arthritis, so definitely certainly something to consider there. The patient in the top right is getting the posterior tibial nerve stimulation which is a small acupuncture needle to that area, little bit of electrical signalling To affect the s. three nerve. And then lastly is a sacred or modulation which is a pacemaker for the bladder, which is another option. Okay so the next one is elevator spasm. And this presents in a lot of different ways. This can present is your patient with pain with intercourse or pain with insertion or inability to tolerate intercourse. Penetrative intercourse with an opposite sex partner because of of the spasm. Um This can present as pain when patients walk. Present as pain when patients exercise. Um It can present as a U. T. I. Patients sometimes say I had a patient today I always have these U. T. I. S. I have intercourse and then I get a U. T. I. Run and I have a U. T. I. It's really important here to tell them and say when you say you t what do you mean? What are your symptoms? And patients will say things like I feel like I really got to get to the frequency urgency in those situations. You always want of course get a urine analysis with culture as appropriate because many times they won't have an actual urinary tract infection but will feel like they do because it's the elevator spasm or held it for my algebra, those muscles contracting when they should. So this spasm is this dis coordinated contraction spasm more common in things that relate to pelvic pain. Will see patients have issues with avoiding issues with defecation if difficulty with inserting Tampa. This is often associated will see patients with ptsD with trauma, with sexual abuse, history of trauma and abuse and those types of things in this patient population is always important to assess that and ask patients about these issues because they can either manifest from trump from physical trauma but also emotional trump. So with treatment here we see public for physical therapy, this is the biggest one. We have four excellent female public for physical therapists at UCSF. Many other great ones in the community. They are fantastic to work with and they can help these patients tremendously. Things like yoga acupuncture relaxation can be really helpful in other difficult cases. You can use vaginal valiant flexible, even belladonna suppository, all things that can be manufactured and done it. Um uh compounding pharmacies. You see an example of the pharaoh on here, trigger point injections. I had a patient earlier today that we were starting on dilator. There's many different ways that we can work together to treat these things. I do Botox injections to public for I do injections of steroids but that is much further down. I always want to give a really good round of physical therapy, these other non injection medication things first. But overall we can definitely get to that later on. So lots of other opportunities in the future for innovation. The last topic I want to cover before I want to take another break and then kind of wrap up our discussion is patients with recurrent U. T. S. This is a huge issue. This is one of the biggest patient populations that we see. And I'm sure many people on this webinar see this often as well. Um The typical patient is postmenopausal in this case 67 67 years old. This patient's having every 2 to 3 months having a U. T. I. They're having frequency and urgency. So what questions should we ask? It's always important here to say and I ask this of my patient today who came in. When you have these symptoms, tell me more about these symptoms. What are they um when you have the symptoms, have you gotten urine cultures for urinary analysis? Can you share the results? And often thanks to uh you know E. M. R. S. Being electronics and shared in my chart at a patient today who is the one medical patients. And they just pulled up on their phone and showed me share their screen and showed me their urine cultures. I can often see them through care everywhere. But then are my chart E. M. R. And epic. It just depends. It's really important to get that data past medical history. Things like how often have you had these and when you were a kid, did you have surgeries on your bladder or any kind of weird anatomy that they had to deal with. Previous kidney stones, medications, diabetic medications? Some of the ones that can cause glucose urea can be really an issue with U. T. S. Diabetic control. Those are some of the and then we'll talk a little about diagnosis and treatment here. So let's talk about diagnosis. So with diagnosis, U. T. I. is diagnosed by symptoms and a positive urine culture of greater than 100,000 colony forming units of a deleterious bacteria. So it's pretty specific when we talk about recurrent UTI. S. That's two or more in six months or three or more in 12 months of these culture proven utilize. So it's really important when I get referrals for current. I'm always grateful to meet patients and work with them. But it's the rare it's the rare situation that a patient meets this criteria. And so it's really important if they don't meet this criteria that you order standing your analysis and cultures that you start to get the patient when they have symptoms to get these urine tests. So you can build that data to support whether they do have a current urinary tract infections or have something else that we mentioned. Things like elevator spasm or very commonly a newer term, which is called genital urinary syndrome of menopause, which is a vaginal atrophy, which will cover here in a moment. Patients after menopause will have vaginal atrophy will have urgency and irritation, narrative symptoms which are very commonly confused for you. T so it's really important to examine these patients, see if they have atrophy, which almost all postmenopausal patients will and then discuss some treatment. We'll talk about in a moment what other tests or imaging should we do? You don't have to do anything in the beginning but over time with complicated patients, previous mashed surgery or other issues concerns for stones will do systems can be looking in the bladder, will do ultrasounds and things like that. Then let's talk about treatment. So first of all for the if a patient has a culture proven you do you want to treat it? And I treat based on sensitivity especially if patients have a lot of ups they can have resistant different antibiotics. You always want to evaluate what are they sensitive to. Another thing to really harp on is what antibiotics to use. So we use a lot of macro bid. Not prolonged use of macro bid but short courses for treating U. T. S. Followed by things like to flex. Try method. Prim um fossil mason and then vary down the line. You want to think about Cipro. We're using Cipro much less with these. Consider I'm waiting to use something like Cipro not using the amoxicillin. Uh sort of start with the macro bid Catholics. Try method for impossible. Listen, those are really the best bets first less side effects to patients more effective for the known causes. I. E. Coli have U. T. S. So lastly with this subject let's talk about preventing you. Do you have a patient has recurrent UTI. S. What do we do? What do we kind of start with? We get first will get the data every time they have symptoms they should get a urine analysis with reflex cultures. You get that data treat based on the sensitivities and positive urine cultures. But let's prevent them in the first place. So that's replacement with vaginal estrogen which can be given as a pill in the vagina as a cream in the vagina. Whereas an estrogen which is that silicone estrogen releasing photos estrogen releasing ring that can be placed in your office. So all those are great formulations. Over a couple of months the patient will be re estrogen. Ized they'll have a change in the ph of the vagina which will promote a healthy microbiome or balance between the good bacteria. The bad bacteria reduce the E. Coli burden and reduce the chance that equalized propagates through the short familiar we threw into the fire, causing other things with less evidence but are reasonable to try in a low risk or de manos, vitamin C. And a vaginal probiotic. So the probiotic that we may take my mouth placed in the vagina once a week will give acidophilus and lactobacillus and other healthy bacteria that can repopulate that well estrogen Ized supplemented vagina help prevent et lastly as hip rex you can use hip rex which is the phantom E. Which is very effective. And then antibiotics. So really down the line and a patient has failed. All these other things has had systems and CT scans. We've ruled out other causes. If we just can't beat these things you can consider postcoital antibiotics which is a short course antibiotics or one antibiotic after intercourse if the patient only gets utilized after intercourse, which generally are younger population, but can be anybody episodic, meaning that you give the patient available prescription that they can fill themselves and take just with the episodes or lastly daily suppression, which is once a day, which again, I would caution against macro bid because of the risk of pulmonary fibrosis and long term use. But you could consider Catholics or try method prime or a few other options there. The last couple of slides I wanted to cover here where just a couple of things that we focus on here at UCSF and I focus on with my practice and my research and that's a value based women's health care. So, you know, with value based, what we're talking about is the balance between quality and cost. So we're trying to maximize patient outcomes and minimize costs and balance those two things. So, um some of the research that I've done that's been published has to do with um improving outcomes for patients by advocating for effective safe treatments like the mysteries of swing for stress hearing comments that I've done studies through the Kaiser system that I work closely with. I'm looking at large populations and verifying the safety and efficacy of that. Also showing that it's really important to have a high volume provider in this case surgeon to do these surgeries. Um these surgeries are being done in the community by many people in different settings. I'm a fellowship trained specialists in this field. I have additional three years of training and a second board in this and I do this procedure 150 times a 200 times a year. And myself and others have published data that says that patients having surgeons that are higher volume that do these procedures more commonly have better outcomes and less complications. So really another important consideration because we take care of our patients. Um the last couple of things that we do here at UCSF is enhanced recovery after surgery. We have a pathway at UCSF that's used often these types of passwords used throughout many hospital systems. When we use this, that helps our patients recover more quickly from surgery. We get them home more quickly. They have less stress, less destruction to them go home more quickly, less pain, less cost to the system. And we've shown also related to this that because of all these advances in our approach to surgery and recovery from it, that we're able to send patients home the same day from surgery um safely, especially during covid. This is so important. This reduces our patients are often elderly, their risk of being in the hospital around other covid around patients web. Covid it reduces, you know, exposing them to other things like the flu in the hospital. And patients prefer when we survey patients, patients and the vast majority for for to go home and be in their own bed, comfortable with their own families rather than stay in the hospital. We've shown that it's actually safe to send patients on the same day. There's no benefit to keeping overnight and were able to do things like that here at UCSF. The last slide I wanted to show here was just a resource that we have for our patients and providers. It's voices for public florid disorders and dogs is our national organization, which the U. G. S. With lots of great resources on their patient pamphlets and our international group, which is why you G. A. Has pamphlets in many languages. Often there Um five or six languages, including Spanish Cantonese, Vietnamese, many languages that are patients speak. So I really try to meet our patients where they are, give them patient resources in their in their language and help them through interpreters as well. Make sure patients from whatever community in any background have an understanding of their condition and their treatment options.