Labial, Vaginal, and Sexual Function Surgery with Dr Oseka Onuma

Labial, Vaginal, and Sexual Function Surgery with Dr Oseka Onuma

Trish

Hello listeners it’s Trish Hammond here from the Transforming Bodies podcast. And today, I’ve got something really different for you. We’ll be talking about labial, vaginal, and sexual function surgery and I’ve got Dr Oseka Onuma who is a Cosmetic Gynaecologist who specialises in labial, vaginal, and sexual for function surgery and medicine, and we’re gonna have all these questions answered today. So welcome Dr. Onuma, how are you?

Dr Onuma

I’m very well Trish. Thanks for having a chat.

Trish

Oh, thank you so much for joining us today. So first of all, tell us how did you get on, tell us a bit about your career. Like, how did you get started in or, like, what made you, first of all, choose this area of medicine? 

Dr Onuma

It sort of chose me. Anyway, I actually got into the whole field of Obstetrics and Gynecology because I really liked delivering babies. There’s nothing like seeing a baby being born, being the first person to touch it or delivering a baby. And that’s really what got me into the specialist field of Obstetrics and Gynaecology. I don’t deliver babies now and I tend to fix all the problems. In the early days of my training, I actually thought that when women had gynaecological surgery particularly where they had problems with their pelvic floor functioning, continents, pro lacks sexual dysfunction, that all the type of treatments we offered them were not very good because I’d be an attendant with a hundred patients in England and I’d be reviewing a whole series of patients from different specialists operating lists. A number of them seem particularly happy after surgery. Until I worked for one particular person that checked all my humans who’s now retired in Birmingham who was one of the top three euro gynaecologists at the time in the UK and he taught me under his wing, which was the best thing. I don’t know why he did that, but we got on, like, a house on fire, and he just taught me. And the interesting thing about his technique was that he’s very much about the patient, the anatomy, and functional outcome and it was really my stepping stone to urogynecology and pelvic floor medicine surgery. But nobody even then took much notice of sexual function and cosmetic orthopaedic gynaecology. And in fact, even now, there are very few specialists around the world who focus on that. And I think it should be a core part of gynaecological training, but there’s nowhere in the world in any training program where social function and aesthetics, the cosmetic components, are taught and funny enough I was at an International Urogynecological Association meeting in the past 2004 and it’s great meeting, but I was tired and I ended up just completely inadvertently in a French bar where I’ve told some other people who want to meet specialists from meeting. I was tired and my wife said that you just go and it’s a couple on social. I went and I met a guy called Jack Hado, it is and at that time he ran and still those were one of  the top aesthetics and gynaecology clinics in Santiago, Chile and also met a couple of guys John Miklos and Robert Moore, who are the Euro Gynecology for the International Standing in Atlanta. Anyway, they took a shine to me, we’re talking. We had very similar interests about sexual function, pelvic floor, and aesthetics and I had thought about training with David Matlock, well known in Los Angeles with Laser of General Surgery and Sexual Function Surgery, but he didn’t really train that many people out as UK at the time because you have lots of people going in that direction. Anyway, John Miklos has flipped his phone open in the middle of a noisy French bar. And David, I’ve got my friend here, and he just met me and you’re gonna train it. And that’s how I really went down the road of specialist training and advancing sexual function and cosmetic surgery. Mhmm. And now I’m a pre-sector. I teach it and I lecture nationally and internationally. I’ve just returned from a trip to Santiago where they had their first intercontinental meeting between the European Gynecology Society and the Chilean Society, which is held in fact, yeah, get an announcement meeting. And one of the things it did apart from me was sharing information and expertise with a whole diverse group of people from Europe and also in South America and North America was that there is an increasing group of people who take quite seriously female sexual function and aesthetics and pelvic floor function and that group is growing steadily. Sorry. Go on.

Trish

Oh, I was gonna say it’s funny because it’s like, you used to hear so little about it and you still hear not very much about it, but it is kind of creeping its way to becoming more of a talked about topic, hey. 

Dr Onuma

It is and look, that it is good. It’s still very slow. Imagine a scenario in two thousand and twenty three. Where if you use the word vagina on social media, you can’t, they will take off what you’ve posted. And vagina, it’s just a normal part of the female anatomy in the same way as penis is a part of the male anatomy and you have to lift in an ankle and an elbow and a head and a neck. But — Yes. — for some reason, society has got it in their brain that the concept of all the vagina should be hidden words in the box are not opened, just peaking once in a while, which is very sad because it disenfranchises women and is a significant obstacle to them getting good healthcare and getting good information.

 

 

Trish

Yeah. Well, it can be it’s really for a woman, it’s kind of like it’s a really hard topic to broach but then once you start to talk about it with other women, you know, people are kind of a bit happier to open up. But I don’t feel like you’ve written a couple of books like and which is really great because it’s really informative and it’s a great way to help women who don’t necessarily wanna speak to anyone else that kind of read wanna read it about themselves or discover all the information about for themselves without actually speaking to anyone. So do you wanna just like, let’s run through about, like, your books, like what’s in each room? Because I know that the first one you did was what you wanna do for labiaplasty?

Dr Onuma

Yeah. I’ve been meaning to write a book specifically for patients. So anybody who’s thinking about their pelvic floor and getting help because there’s lots of information on the Internet, but it’s all all very, very limited and, like, just a paragraph and stating that we can do this for you, but it doesn’t tell you anything else about anatomy, the condition what might benefit you, what the potential outcome for, what the potential bad that comes up and so I thought to myself, well, if I’m going to write a book, I didn’t try to write a book. The first book I tried to write would have been maybe about civil or eight books worth and nobody would have read it because I was thinking about the pelvic floor as a whole in terms of influence on some relapse and so on. And after a couple of years, I thought, well, nobody’s actually going to read this. So let me just focus on an area which is topical, really misunderstood, an operation which I’m really good at, which I enjoy doing and where I think when it’s done properly, if the outcomes patients are excellent, just not in not only in terms of their physical health, but their psychological health and their ability to engage in relationships and that was the labial surgery. And so that’s the first book I wrote, specifically for women and it really is as of what I said, not a book to sell the procedure to any individual. But for one, if you’re really thinking about it, here are the things you want to know. And it begins with bringing a little bit of knowledge about the anatomy that I get numerous inquiries from all around Australia and internationally. And if often, they’ll say, well, I’m wanting a vaginoplasty when you explored it a bit further, they didn’t want anything to do with the drug. They’re talking about the vulvar and vulvar, it’s a labia. So terminology is important, and understanding of anatomy is really important and those are two areas which makes it very difficult for the patient to convey what she wants and for the doctor if they’re not careful to understand what that individual person is requesting. So, anatomy is important and the first part of the book addresses Volvo and Vagina Anatomy and then I go on to talk about the different types of complaints that women have that leads them to thinking about having labial surgeries and in my experience, most women who want labiaplasty have a functional component, a number of discomfort. If you look at the media, you would be forgiven for thinking that most women who want a labiaplasty the one is for cosmetic concerns and therefore it’s frivolous and they should be dismissed. Obviously dismisses men and women who want to improve their lives above the shoulders. But if it’s anything to do below the waist, in a man that’s a K-2, like peanut implants, etc. But if it’s for a woman talking about the vulvar vagina area, they do tend to get weel, short shrift, not not very much attention. It’s also hard. Yep. So the book then goes on to explore different types of labiaplasty surgery, different approaches that different groups of people use, the type of people that might be doing labial surgery and also examples of outcomes. So I’m not just talking about the labia minora, the inner labia, which is the most common area that women often seek help with, but also the labia majora, the perineal and the whole pubes of the area surrounding the labia minora and so that was my first book. The second book is…

Trish

The Ultimate V? 

Dr Onuma

Yes. Yes. It was pretty funny because at the time that I began writing the labiaplasty book one of my close friends actually said to me, you know what? Don’t write this. You should write what the book is now, the Ultimate V. Because she said to me, really, women just want to know globally. They don’t want lots and lots of detail, but they want to know about all the things that happen to them in a succinct manner. And I said, well, I could do that, but I want to write the labiaplasty book first and I did but now I’ve written the Ultimate V  like and I actually really understand now with how it’s been received why she was advising me to write the Ultimate V first. That’s because the Ultimate V is a book that fell off by saying, in fact, there’s no such thing as the Ultimate V, the ultimate vulva or vagina or the vulvar vagina area. There isn’t an ultimate in the global sense because everybody is anatomy and presentation and their perception of their own general areas is completely different. You can’t see, there’s no standardisation at all. And a lot of the problems that women complain about, if you look at it in terms of visually in terms of anatomy. In this case, there are differences and for those people, those differences can change over a period of time suddenly or have always been there, but they haven’t been able to address it until the time for whatever reason it was relevant. So for any individual person, they do have, I believe, their ultimate v. And it is the function and cosmetic appearance of a vagina area which works for them, which makes them comfortable, which makes them not embarrassed, which allows them to engage in relationships to allow them to have the light on if they want to walk around, to dress well, to be confident that if they meet somebody, they’re not ashamed about how things look feel or work below. And that is any woman’s ultimate v. Now, the things that they may need to do, to get to that place again, it’s very different because whereas one person might have an issue with the lens of the labia and of all, when that might have an issue with scarves and tears at the entrance of the vagina as a result of former such as childbirth or an instrumental delivery such as four sets. And then another one might have a medical condition where the labial few such card engagement end of course, and other might have a lot preventing it from prolapse somebody might feel that the vagina is too open at the entrance and that lacks inside and they’re getting squishy noises, which they’re really aware of and that they feel that in a social setting, somebody else can hear and so the problems are numerous — and many women will have more than one complaint. But again, what works for them will be unique to them. So this book really says, okay, here’s the common types of problems that I see in my working practice that makes women ashamed about their pelvic floor area and these are the courses, this is the presentation, then I use, the identified, emailed from patients using their own words to describe the problems of pain need help with. Because those words are often, in some ways, repetitive. I can be asking a patient in front of me on the phone, on a video call, from another part of the world and the words that they’re used to describe a particular issue are I can always take the words out of them and sometimes just wrong with it for them and particularly sometimes patients will start and you can see they’re getting embarrassed and they stop. And they say, oh my god. Well, maybe I’ll help you and I’ll just throw some words out and see if any of those words, uh-huh, what you’re trying to get out. Yeah.
No. I want your words, like, I can’t feel anything or it feels it just feels if you’ve been there, but I can’t engage. I’m not feeling part of it. It feels too loose and they’re nodding and say yes.
Yes and it’s really a cathartic experience to be talking to another human being. And helping with the process of just describing the problems they’re having, and then they start to tear up, we start to cry and they’re not crying because they’re anxious or depressed at that particular point in time. They’re not actually crying because in their own words, they have found some of the youth actually listening to what they’re saying. So at that point, I actually haven’t offered them anything. I haven’t done anything else that you sent down and listened to because I have listened over and over again and those stories have been repeated. Doesn’t make me a genius. It just means that my ears are open and I’m willing to listen and I understand where they’re coming from and what they want to achieve. Mhmm. And that is quite it’s been one of the most interesting parts of my journey going down this road of sexual function, and I said it gynaecological medicine.

Trish

So just so, like, so that people listening can kind of not have an understanding, but let’s go through, like, the procedures one by one because I think that’s what people are kind of interested in. Like me, for example, what’s the like, there’s labiaplasty, there’s vaginoplasty, what’s the difference between that for a start because I have people saying, oh, I need a designer vagina, or I need a labiaplasty or look like let’s start with the first one so labiaplasty -so what is that surgery?

Dr Onuma

Okay. So the labia are the tissues on the outside of the vagina and are part of the vulva. So if we look at the area from all around the vagina, the bit right at the top, the most pubis, just that was little fat, just above then you’ve got the labia below. The labia split into labia majora or the outer labia and the labia minora or also in the inner labia. And then you’ve got the tissue that comes down below and tracks down towards the back passage. You’ve got that area, which we call the perineum, which is below the entrance sort of vagina. Now, the majority of women who request a labiaplasty, a new type of labiaplasty, usually want a reduction, that’s a reduction in size of the inner lips, the labia minora. They usually wanted them to be symmetrical, reduced, and not longer than the protuberance of the outer labia, and other the labia majora so they’re more tucked in and neat using patients’ words. Now that’s a vagina.

Trish

I’ve definitely heard those same words I’ve heard neat. I just want it neat and tidy. Yeah.

Dr Onuma

And then the vaginoplasty could only refer to surgery within the vagina walls. Now, technically, the vaginoplasty means a modified surgical modification of the consumables. It doesn’t tell you whether you’re making it tighter or looser. Now in practical terms, the majority of women that I see in my practice who want vaginoplasty surgery, so it’s a surgery within the vagina, want the vagina to be tighter. They call their feeling better to revolt of pregnancy, childbirth, genetic, normality in their connective tissue, pregnancy even without delivery for the hormonal changes, that the the vagina is too loose for them and if not all of a complaint of inability to orgasm them because that’s in itself, although linked is a separate issue. What they want is the sensation, the increased friction without discomfort so that when their partner it’s in them or whether they’re using a sort of an instrument, then they can actually feel that there is something there. And so somewhat for most women, that really relates to the internal part of the vagina and for the majority of those women, that also includes the diameter of the entrance, so a number of that muscle at the entrance, the peritoneal body, which keeps the vagina tight and looks rather than appearing open. So then it’s quite like, you then said sort of labiaplasty and vaginoplasty and then you sort of at the same time, you said that design of vagina. The designer vagina is a bad term. It’s okay. It’s really good, none of that. I’m not giving you a hard time. I’m just saying, I actually quite like the terms inside the vagina. The problem with the term designer vagina is that women who say they want, which I mean, you can’t actually tell what the problem is and what outcome they want. It’s impossible to tell whether it’s a labia, the once in pubis, the perineum inside the vagina or at the entrance of the vagina. Okay. So if we’re being pedantic, I think we do need to be present and get the anatomy right so that our communication is more accurate between doctors and between patients and doctors between women who might become patients, but also discussing it with their friends so they’re on the same wavelength. We need to see the giant is within the vagina and labia that is outside the vagina and once we get that simple distinction, a lot of the problems of miscommunication will disappear. So a designer vagina doesn’t tell us anything at all. You can design a vagina inside to be wider, looser, tighter, or use medical instruments or things like plasma to increase in facial blood flow, improve the chance of orgasm or intensity of orgasm. But again, designer vagina sounds like a life term is often misused, abused, people laugh at the term, it doesn’t tell us anything so I think we shouldn’t lose it. We should be more anatomical about the genital area.

 

Trish

Yeah. Of course. I agree with it and it’s funny it almost starts from just because you’re a woman and you’ve got one doesn’t mean you even know anything about it.
You know what I mean? Like, and and we’re not kind of taught from the time when we’re young, it’s not something that we kind of talk about too much or share information about except perhaps with, a close girlfriend or and that’s not even all of us. Most people probably wouldn’t but it’s still quite taboo to even talk about.

Dr Onuma

It’s not all yes. Still, I had a patient, a delightful lady who was in her mid seventies, and I had not pressed on her a combination of prolactin content surgery. She came back for a final review some four months after surgery. It was great, happy and I discharged her and she was not upset. Thanks very much, walked off to the door, and then turned back and said to me, I’m trying to ask you a question? Also, I said, sure. No problem. And said to me, I don’t know where my catheter is. And I’ve been meaning to ask you that I’ve never had the confidence but you’ve fidget me well and thought that I’m going there. I need to ask, is it here? Can I show you? And so we went back into the examination room with my chaperone, and I showed her where her catheter was and she left with a big smile on her face. That is a problem. Yeah. Seventy year olds, my younger patients in their twenties will often use terminology, which shows that they do not understand their anatomy in hospital when we have to put catheters in patients for a variety of reasons. Even some of the best nurses don’t know where the urethra is, let alone the patients who know what you had to classify the patients so lack of knowledge about female genital anatomy is a significant problem. Yes.
It’s a big impediment to getting good care and or anyone knows about her, and that’s her own anatomy, the more protected she will be in case of any changes, but the more likely that she can access better care because she is using the right terminology. 

Trish

And so what about so because I’m just gonna talk about surgical procedures first and we’ll talk about non surgical stuff that you can have done. What about sexual function? So do you know you kind of spoke about that a little bit now? But what sort of options are there for people that might be just having problems and not specifically knowing what it is. So I know that’s a pretty open ended question here, but.

Dr Onuma

It’s a pretty open ended question, Trish. It’s great. But I can summarise it in principle really easily. The two main problems that I see for women who talk about issues with the vagina – it’s too loose. It’s not like it was before kids saw when I first started having sexual intercourse and you hear these sort of really unhelpful comments by some doctors who say in response. Oh, so you want to be like a virgin. I suspect a model woman is a man but I suspect that no woman really wants to go back to being a virgin. What my understanding is after having this type of conversation several thousand times is that what women tend to want is to have a vaginal diameter that is akin to what it was when they first started having sex, not when they were virgins, but when they’d been having and before kids. In other words, it was most fitting, they could feel, yeah, they could squeeze, they were engaged in the process because of that physical interaction. So I’m not talking about psychology. I’m not talking about relationships. I’m just talking about the physical act of sex and the ability to engage in it because you have sensation. And again, that’s different, the orgasm of which although links it is another matter altogether. Now the other problem that some women have is, of course, they cannot engage in sexual intercourse because of pain and pain can be for a variety of reasons and in medical terms, we call it painful intercourse. We use the word dyspareunia and then we talk medically about deep dyspareunia, so pain right at the top of the vagina, and we talk about superficial dyspareunia, hanging at the entrance. Now, hang at the top of the vagina. And it’s what’s at the top of the vagina? Well, and you got a uterus, it’s a cervix which is the beginning part of the uterus and that uterus has got support. And if you don’t have a uterus, then you’ve got and you’ve had a hysterectomy, then you’ve got the one we call that the giant wolf, just the top of the giant, which is closed off. If you have deep dyspareunia, again, it is often positional and the position that usually causes the most discomfort is when a partner is deepest and that deepest position is often if a partner is behind. Because I’m able to say, well, I can only have sex in the missionary position because if it’s behind, it really hurts and then you say, what does it feel like? It’s sharp. Does it feel like he’s hitting something? Yes. It’s like he’s hitting something at the top and that’s when you understand as a surgeon that in fact, what they’re hitting is the top of the vagina, which is prolapse or the uterus, which is prolapse to moving up and down, and that stretch is not interpreted by the brain as pleasure. It’s actually painful. It sets off the pain receptors. Now happy entrance to the vagina. One of the most common things that cause pain is cut issue, but cut issue can arrive without any known preceding event, it can actually be the outcome of surgery.
So you can have surgery to fix something and you end up with pain because you’ve got a scar tissue wave two times, or but the most common one of the most common reasons for painful intercourse is actually an outcome of childbirth, where you’ve had a cut to facilitate the babies head coming out, or you’ve had a tear of the the vagina walls, particularly the entrance, or you’ve had both, you’ve had epitome of the cut and you’ve torn all over the place and fine to repair that entrance to the vagina, which is torn, less rated bleeding and the swollen after the baby comes out is really challenging and in more than ninety percent of cases aren’t satisfactory. Why is it satisfactory? Because in most cases, in public medicine, the people, the doctors who are involved, are called in by middle rights to deliver babies when it gets a bit sickly, are junior doctors. Oh, I’ve no experience in, you know, basic reconstructive processes, little and one where the anatomy is in shredded. And secondly, they’re often women that just passed on the head and say, oh, we just put a couple the inner tuck it together, it’ll be fine. And, yes, it’ll stop the bleeding at the time, but they always end up with scar tissue. They often end up with painful intercourse, and they often end up with the anatomy being distorted so they end up they can’t have intercourse because it’s too painful, and they don’t want to engage in the end course because of the pain, and they don’t like the way it looks it looks scar tissue. So pain and lack of sensation are the main two issues we deal with. There are others, but they’re less common.

Trish

Yep. Yep. And what about I know we’ve got, like, people that have their hymen, well, I don’t know, prepared or whatever. Because I know it might not sound like a lot of people that it’s a thing, but it’s a thing. Is that a thing in your clinic? 

Dr Onuma

It’s a thing. So they’re two okay. So if you say hymen surgery, nobody says that. They tend to say hymenoplasty. A hymenoplasty or surgery of some kind of a hymen and being two different things. One, you are exercising hymen and the other is you are repairing the hymen. 

Trish

So repairing is what I mean, then yes. 

Dr Onuma

So repairing the hymen is a function of, I believe, misogyny. Okay? In other words, if we didn’t have cultures or religions or that seemed to demand that women are very good, intact, and have an intact hymen when they get married, there’d be virtually no requests or very few requests, shall we say, for hymen repair surgery and in a country like Australia, with a gradual increase in immigrants from different parts of the world. You see an increase in the number of requests for I meant repair to satisfy the proper knowledge of all religious requirements for marriage. Now, most people think that it’s just Muslims that make these requests and in practice, they are the biggest group. There are also Christian groups who have similar requests and once in a while, you get people who request hymen repair, not for religious reasons, but that’s a quote unquote gift for their partner so that’s repair. But again, the majority of them are related to culture and that it just backgrounds where or the woman who does not have an intact hymen because she had been friction active before marriage, the implications for her and her family are dishonour and even death. Not insignificant at all, those problems. 

Trish

Absolutely. You know, it’s funny what you said about people coming in from overseas because I’ve got an Italian background, and I’m a first generation Italian and my parents came out here in the late fifties, early sixties or actually probably late fifties, both of them. And it was a requirement that the girls had to be virgins when they got married and even when I got married at the age of nineteen, my mother-in-law at the time was of Greek ethnicity. She wanted to see the sheets for that very same reason. So it’s a big deal about big debates about that even not just like you said, not just Muslims, but that was just Italians and Greeks. In the eighties that’s crazy.

Dr Onuma

That’s right. It is crazy when you think about what you’re really asking. So  yeah, I had another experience as a traveller many, many years ago, but thirty years ago on a trip I won’t say which country. Let’s just say it’s a country in Europe. Okay? And I met a group of guys who seemed to like me as one of the first black people they’ve met and we’ve gone on very well. They thought that very much that wasn’t, but anyway, they’re really good. But I chatted with them over a course of three or four days and what I found was that they were not allowed to have relationships like marriage. But if they did, it was fine as long as they didn’t get what I mean, if they got caught and it was a wrong family, then they’d be in trouble. But if they didn’t get caught, in terms of getting married there was no impost on them to show that they were virgin and never had any of course. There’s no problem at all. The same couldn’t be said for their sisters. So if they’re sisters and they’re very protective in an inverted protective, but their sisters who were expected not to even talk to boys, let alone, engage in sexual activity before marriage because that would lead to dishonour. Now interesting enough, the reason why I mentioned this story is that the the importance of that was drawn into me by the fact that In us in that society where being homosexual was taboo, those guys and this is what told me, were much more likely to engage in male to male sexual contact, not perceiving themselves as homosexual rather than having sex with a female in case they needed to marry them or come into conflict with their family. Though the problems are actually quite significant and cultural and embedded in the society and how the society in different parts of the world behaves and those societal pressures do travel with groups of people when they change countries.

Trish

No. It’s funny. It’s just so, like, they’re just seen as so foreign to most people, but I can understand it and the need for it and whatever. So another thing I was gonna ask you is that the next one I was gonna talk about was the mons pubis reduction. So that’s something that’s like to tell us a little bit about that because I know a lot of people out there that have got what they call a there’s actually a name for it, which I won’t repeat. 

 

Dr Onuma

There are always terrible names for things that appear to be wrong with the female genital area and then there are any terms for the female genital area which are colloquial, which are good. I might tell you the most previous is interesting because it’s an isolated area of the vulva, which sits above the labia majora, sits above the vagina, and that sits below what we would say is a lower part of the abdomen. So there’ll be a whole group of and you can tell it is clearly marked in position because when and we’re talking about women not men. So when women have an abdominoplasty where they’ve got extra fat or lost weight, and then they have the surgery with the skylight long the lower part of the abdominal when they have that surgery done and all that excess skin and fat is removed, it does nothing to the area below that because there is a natural anatomical junction between the lower abdomen and the beginning of the bolus and that if you pull up on the lower abdomen, it doesn’t pull up really hardly at all the mons pubis. The mons pubis is its own area and in fact, the only part of the immediate anatomy that makes a difference to how the mons pubis looks or how it sits or how prominent it is, that’s a small degree, is what happens with the labia majority out of the outer layer. A large, isolated area, which is on the skin, you’ve got hair cells on the skin and below the skin, you’ve got a whole lot of, you know, fat effectively and so for some people when they drop weight successfully they may or may not have an abdominoplasty to tidy up this skin, but they’ve got their five legs there, and the most people which remains, you know, like a patch in front of them and so they’re uncomfortable getting into a bikini. They’re uncomfortable wearing trousers because of different mounds that they are very aware of that sits in front of them even if the rest of their anatomy is within a normal BMI sort of body mass index. So even I’ve seen numerous patients who have never been overweight and they’re sitting everywhere else, but I’ve got this isolated mound in front of the multiple bits where it’s at large and the fact just doesn’t go even if they tried to do all sorts of slimming techniques.

Trish

Yep. Yep. Now that is some very common yet title. It’s a and it’s a really popular procedure when people have had a tummy tuck because it tends to kind of just lift everything up and make that bit pop out. 

Dr Onuma

It’s tough, but the interesting thing about it is that the majority of women who have a tummy tuck, who could also do with the reduction of the month previous, don’t have it done because then there’s not that many people trying to do it, and it’s not offered. It’s not sizing at all– an afterthought, whereas it may be the most important thing to the person concerned. Some surgeons will offer liposuction – and liposuction will be effective in reducing the subcutaneous fat. The problem though is then you’ve reduced the fat to what you’re left with, you bet you’re left with wobbly excess skin and so what do you do? You have to go back into a surgical procedure to tighten up the skin and reduce the excess skin. So you’re doing a double win in two procedures. A liposuction, they are going back in the second potentially, second procedure or second procedure on the same visit and then do surgical more surgical procedure excision. The approach I think is to say, well, forget the liposuction.

 

Trish

So what you’re saying is if you were to do a mons pubis reduction, that would be done with surgical excision? 

Dr Onuma

I would. Okay. Because I’ve seen numerous women who have had liposuction and they come and see me and say, yes, the skin is all fluffy and they say, okay. So what if you had done it? I had liposuction and yes, well, it was not as prominent, but it’s all squishy and moving the skin. There are nonsurgical tightening technology if there are, but none of them are good enough to shrink the excess tissue that you have in a mons pubis area when you’ve had the fat removed when it’s been when the mons pubis has been enlarged. So the approach that I take, if I see a patient for the first time who wants who feels that the mons pubis enlarged and is clinically demonstrable if a surgical approach I don’t do, like, recruitment patients because you’re adding in a procedure which you’re going to consume time with, and you’re gonna charge the patient for which in my humble opinion has no value to the with in terms of the outcome. 

Trish

And so let’s talk about nonsurgical stuff then because I noticed that there’s a few things that you can actually do nonsurgically to improve, I guess, the labia, your vagina and sexual function all around. So the first one is, like, improved sensation. So what’s that about?
Well, it sounds alright. But what is that amazing?

Dr Onuma

There are lots of ways of improving sensation and the two classical ways of improving sensation are, if you make the tissues tight, there’s more friction as long as there’s no discomfort. But the non-invasive way is to say, okay, what we have in our arm really improves nerve function, blood flow, and might improve the response of the so-called g spot. And the g spot I think is always something that you can discuss forever with a thousand different professors, but I think in practice, some women have it and some women do it.
And I’m leaving the women that have it. It’s not always in the same place. Anyhow, that’s not the story. But one of the non surgical treatments that is really quite effective, and I use quite a lot in my armoury of treatments is actually platelet rich plasma, which involves taking from blood from the person you’re going to use it on, in a particular type of tube and spinning it in a special centrifuge and what that does is put all the red cells which you don’t want at the bottom and leave the plasma, the yellow fluid at the top and that plasma is that is the platelet rich component, you then take it, and then you inject it back wherever you want it so when I do it. It’s not enough if I do so I got into faces from doing the collatage seem to want to do, but anyway, and training other people to inject, so anyway. The most common area is PRP, a platelet rich type of injections under the face, but we also do it in the vagina. People have oiled different terminology for it. So they might walk when I did my training, but then in 2005, he used and trademarked the term g spot augmentation and Charles Reynolds will recently have a market term O-Shot, which is a series of injections, then the so in the G spot area and in the area of nerve supply for tissues, no matter when your fort. It’s the approach where you put in a natural product with the patient’s own fluid containing cells that are engaged in rejuvenation, improving them in blood supply, fibroblasts to improve the collagen, the elastin, and nerve function. Back to wherever you want in the vagina was trying to improve the vision. The other area which bit it has proved really valuable in my practice, it’s just it’s not sufficient alone. Some women when they operate on the vagina walls are prone to scar tissue formation and many already have presented with scar tissue as the problem that’s having scar tissue and rebuilding and putting things back together. Some people will have a pretty deficient previous position to form a scar and platelet rich plasma injected into those areas, the before surgery immediately at the time of phrygians sometimes after surgery, it reduces start tissue and improves healing and improves good sensation as opposed to pain or discomfort. Now if there are other agents with similar effects as platelet rich plasma and some of those things are products derived from amniotic fluid so amniotic fluid is the fluid that you get from the younger microsim baby even we can produce and they’re targeted down into their commercial preparations of these products around the world, some artificial, some are natural, but they all have a similar type of outcome.

Trish

And some people are using Botox? Or filler?

Dr Onuma

Right. So they are and again, they’ve got very, very different indications. So let’s deal with the botox in the vagina. Botox in the vagina is a no no for any woman who wants to improve sensation feedback, orgasm, and vagina is just don’t do it. Okay? So the play for Botox in the vagina is really to do with painful intercourse room resulting in vaginismus. Now, vaginismus is a condition in which you have involuntary contraction of the muscles of the vagina in response or in anticipation of pain and can be so severe that it makes the vagina impenetrable. It just locks up. Now BOTOX is one of the things that can be used to prevent a muscle function. So in the same ways you might put Botox in the face to depolarize those muscles so that you don’t get wrinkles because you can’t contract the muscles.
You put Botox in a specific way in the elevator muscles of the vagina so that it doesn’t contract in response to pain or anticipation of pain and that can work but doesn’t work for everybody and it has to be take place really carefully because, obviously, if you get Botox, migrate down towards the peri anal area there around anus and you deep bone ride those muscles, then until it stops working and it will stop working because it’s not a permanent treatment, then if it affects the muscles around the peritoneal region, then you might have faecal leakage for up to three to four months as you’re gonna have Botox in the vagina for pain and vaginismus must find yourself somebody who’s got lots of experience.

 

Trish

Yes. Sounds really so good. 

Dr Onuma

Why? Well, like anything, but, you know, particularly things like Botox in the vagina and you also mentioned you’ve lost me now. Before you talk about it.

Trish

Oh, filler. 

Dr Onuma

Oh about filler, yeah. Alright. Now filler again, very topical in the face, lips, and so on. There’s lots of hyaluronic acid and other types of fillers around, which you wouldn’t get into. But in the vagina, fillers are increasingly used by practitioners, mainly in the vulva so and again, in the vulva specifically, in the labia majora, the outer labia or the outer lips. And you tend to see this at the moment more commonly being offered to older women where they’ve lost fat in that area. The labia majora deflated the skin is a little more loose on the top, and they want volume back into the labia majora for aesthetic purposes and not often functional. I don’t really like it, and that’s my own personal view but there’s no point anybody at all contacting me and say, will I put filler in their vulva for them? I’ll just say, if you really want that, find yourself somebody else. Because I’m trained to do it, but I won’t do it. And it’s my personal bias and the reason for that is you are affected by our experience. My experience very early on before I started doing much in the way of filler after I trained was that I was actually seeing patients where I was doing complicated surgery to remove either VCSEL filler or the fibrosis and the fact that occurred leaving them with dimple unevenness and more often discomfort. So if I was doing that, I didn’t feel comfortable putting fillers in and that and that’s just me.
I’m sure there are lots of people who have had good experiences with filling in the vulva, but I’m not your person.

Trish

I’m not a patient either. We can agree on that one. 

Dr Onuma

Then filler in the vagina. I think fillers are a non natural product from the vagina in this day and age. Particularly in the environment of all the discussions and litigation of the baton with mesh is completely different. But again, filler is an artificial product from the vagina. Well, I’m a bit too cautious. People do it. I think plenty of other natural stuff, which works really, really well, such as PRP, not certain mechanisms. Which is safe, works really well. 

 

Trish

No. Of course. Well, tell me and and what about so so to me about pigmentation because Like, someone would think, oh, what? Like, so depigmentation.

Dr Onuma

Depigmentation? Yeah. This is almost, but not quite in the two hard baskets. So let me say this, if somebody came up with a really, really good solution, the depigmentation, which was permanent, they would clean up the market. It doesn’t exist and part of the reason is because of how pigmented is formed from the melanocytes that are the one called tyrosine and anyway, so from the basal cells of the skin, you get this, like, a process and lo and behold, the pigments melanin, which is dark, it comes to the surface. Now that is a continuous process and it is difficult at the moment impossible to target all these indolent cells that have not produced anymore met melanin. So all the current treatments and there are some reasonable treatments, often made by pharma or cosmaceutical companies, will make products for which they target different parts of the process of production of melanin in the skin and so apply properly. And for a long enough time, a lot of patients will see less pigmentation, more even tone, but they may need to have, although certainly of repeat treatments in the future because of the ongoing nature of production of melanin. Okay. So anybody who wants depigmentation and needs to be committed to pursuing that treatment in the long term and continuing. Now cosmaceutical treatments are not the only ones, there are medications that also interfere with the production of melanin, which are taken by a template. One of them, the product I’m already mentioning on this, is actually used and that there’s a product that is used very commonly by gynaecologists for helping women who complain of heavy periods and the way it works is in core called anti fibrin and litigation. So it disrupts fibrin production but it’s also very good as a depigmentation agent, but it’s not licensed for use in this country. Mhmm. In Australia. Okay. Got it. But there are a variety of other products. Now, unfortunately, the one of the most effective products that you can put on your skin that will give you a really good depigmentation effect is also very toxic to the skin. And women will still seek those products out. In countries like Australia, New Zealand, the US and the UK, you cannot get those products legally. But in many other countries around the world, you still can get them and the problem is not only they can maybe cause a decline, they can maybe burn the skin, but used in the long term, they can be cancer causing so the most effective treatments we’ve got on the moment in terms of skin application are the most detrimental to long term health, but they are just commonly used around the world. So, yeah, so depigmentation in the vulnerable region can involve medication used off licence prescribed by a doctor who knows what they’re doing. Cosmeceutical products, some of which are very good. But also, you can there are a variety of lasers and the whole field of lasers if a a a talk on its own, but you can use a variety of lasers, which will result in breaking up the melanin on the skin, and then making the skin appear lighter, more even turn at the depigmentation and sometimes what you really need to do to get a really good outcome with reduction in risk is to use a combination of oral medication, contact skin application, cosmetical, and laser in a in a fashion that’s detailed and or for that individual patient. But the important thing is that any patient who thinks that they’re gonna get one off treatment and that’s it, is wasting their time. It’s got to be important enough for them to commit to repeated treatments, a long therapy into that up with the cost and the time that it involves. 

Trish

Of course and alright, let’s finish up with the big one. I I know, like, we’ve been talking for ages and I could talk to you all day but bladder problems and we have a bit of a talk about that because it just seems to be, like, I’m like, there’s a lot of women that you just that a lot of women, especially around, like, a lot of my girlfriends, around eyes are always not having to have a laugh and like, coughing or sneezing or laughing or whatever where they just have a little bit of leakage. Now a lot of I mean, I guess it’s a bit more prominent these days. People know that it can be fixed, but it can be fixed, can it? You don’t need to know if you like that. 

Dr Onuma

We have an unfortunate situation where companies that advertise ads. I’ll advertise within purity and so what that does is normalise it. So it says to women, yeah, okay, you leave yeah. You’re getting older. You’ve had children. What do you expect to have put up with it? And imagine the situation where you’ve got a special rugby player. Guys, break their shoulder, coming down off the full, and they say to them, oh, well, never mind. It’s all part of being a rugby player. What did you expect and send them off? No. What happens to them is they get carted off. They get the most appropriate imaging. The most appropriate kind of treatment is surgery by the best surgeons, and then they get to the best rehab people and learn behold, stay back on the field in two or three months. You want you to think to yourself, all listeners did that happen last time I injured myself. I couldn’t do anything for ages. No. Because those people get the best care. The problem with bladder dysfunction is that it’s been so normalised that it is not perceived as abnormal. It is abnormal. It is not normal to be leaking when you’re on the trampoline with your kids. It is not normal to feel the urge to go to the toilet, and before you get to the toilet, wet your clothes and your underwear. It is not normal to be having sex and either fear leakage all leak on orgasm. They are abnormal. But the way it’s portrayed is that it’s all part of being a woman. It is not. Yep. It is not. And there are numerous things you can do about it. But again, one size does not fit all. The bladder is really, really complicated. Yeah. You can have leakage. You can have difficulty emptying your bladder.
You might go to the toilet. Might be times a day instead of, you know, seven six to seven times during the day. You might be getting up two or three times at night instead of going through the night. Without getting up. You might have pain when you’re emptying your bladder, etc. So on all of these things, problems with the bladder often require different solutions, which means investigate and then figure, well, what do we tackle first if there’s more than one bladder problem? But it means that somebody’s got to take you seriously when you say there’s a bladder problem, including leakage and you’ve got to take it seriously as opposed to saying, well, I’m just going to wear a pad. Now, statistically, there is really fantastic evidence from US, Australian, UK and European studies, which show that your individual chance of ending up in a nursing home is directly related to whether you’re incontinent or not. 

Trish

Oh my god. That’s so you want to say that because that’s just happened to us in our family. Yes. And that’s the reason we couldn’t see. Yeah.

 

Dr Onuma

Yep. But it’s not bad wearing pants and they’re bigger pants and then pants that are, you know, like, big ginormous things and then — been sold. There are lots of things that can be done for bladder dysfunction. Available at this moment of time. Now specifically, about stress incontinence, involuntary leakage, when you cough, sneeze, exercise, anything that increases intra abdominal pressure, including sex. The one of the biggest impediments to women seeking care for that. As I’ve heard recently, and that’s to do with the issue of mesh. Right. So before mesh became available as a sling with a sling procedure – twenty years ago, most of us who trained with expertise in incontinence surgery were doing things like procedures called the burch colposuspension or a fascial sling or and those sorts of operations. Now those operations are specialist areas so if you qualify the specialist of gynaecologists to do that, you’re gonna get extra training because their surgeries are quite complicated, investigation, treatment, follow-up specific. So very few people did it. And then when the slings came along, people found that they were as effective in terms of minimally invasive patients being on their feet for a longer, shorter, shorter duration of time. And most importantly, a lot more general gynaecologists trained to do it, which is good. The problem is that a lot of the surgeons who are trained to do it still didn’t have an understanding of the anatomy of the pelvic floor that those people who trained to do the most complex surgery before did. So when there’s a problem, they had amputations on the head, this is my belief. And say there they well, there’s no problem or and they wouldn’t refer the one to a new somebody who knew what to do. And their technique in doing them may not have been completely appropriate. Nothing much would have happened necessarily with that specific area alone. Had we not had the disastrous situation where, again, I think, the wrong people were using mesh products in the pelvic floor, specifically for complex prolapses. And again, the similarities are the same. People in the past would never have touched the mesh product who wouldn’t have done the complex. Pelvic reconstructive surgeon we had the training with, the mesh kits came out because their kids sort of learned to use them, even without that understanding of the pelvic floor, which was even more important when putting a forum product into it. And so patients were then getting some poor outcomes and passed on the haven’t told it’s nothing to do with us and not referred on and then you and that leads on to the situation in which patients have had disastrous outcomes, litigation occurred, and now you can’t use mesh on many countries around the world still available in places like France and other places. Products on their own of their own issues, but in the right hand, significantly less so they’re going back to slings, which are really effective, are still available in Australia, and which I still do, women are much more cautious about having done because of the bad press the safety issue, which has been completed by the issue with mesh for prolapse, which are the completely different product, different use and so they’re completely different, but everybody hears the same thing, and they put them in the same basket so women and and then it might say, okay. we’ll forget about the sleep. Why don’t I go back to doing birch, proper suspension, and facial sleep procedures we do. Except fewer people can do them these days, and there are bigger operations, in fact, with more complication rates in more increased risk of blood loss, etc. And they’re still relatively safe but if you read the IUs for the purpose of consent, in my patients a very confronting sheet, which I got out of the UK by revision training with this society of urogynecology and which actually lays out fairly fluorescently all the bad things about doing the sling procedure to try and put you off. And I do get my patients and say, if you want me to do this, you need to read that and then sign it for me to do it. And I am very clear, those complication rates are very few in my hands. I can say that and I can afford it to show that I have a really low complication rate but I give them confronting material because we live in an age of litigation. If you don’t want that operation, then you can consider having a burch. But if I give you the one for a burch colposuspension or facial sting. It’s the open cut. We’re dividing the muscle or the rectus cuff fascia etc. If there is a risk of nerve injury, blood vessel injury, etcetera, would you like that one instead? And because we’re living in a day of consenting patients and giving them accurate information. Sometimes they’ll walk out and say a lot, you know what? I’ll put up with it and then they said, well, is there anything less invasive that you can do, not burch, not fascial sling, not and then we go back to the old days. Because in the old years, what we used to do with an anti paravaginal repair, an anti paravaginal repair used to be, forty years ago, the gold standard for expressing content with a seventy percent success rate. Things like Burch, fascial slings, sling procedures if I buy that success rate at ninety percent. So women often say asking for the surgery, which they perceive, has got less risk and no problem from but they wish they accept has got a lower outcome, but that’s what they want. Well, things like better name buttressing in consonants, particularly stress incontinence. There’s a problem with perception. There’s a problem with social media, what it means and normalising it. And then when you get down to the niche group, you’re actually doing something. It’s actually now really a complicated area for patients to navigate. What the different types of pressing consonant surgery are, what it means for them, and what the risk and the outcome for them is. Really difficult.

Trish

Yep. Yep. Yep. That’s just being like, it’s like information overload isn’t it? It’s just like, well,

Dr Onuma

That one was stepping into devil’s territory, bringing the urinary dysfunction at the end of that.

Trish

Yeah. — I know. I I know. You know what? Because it’s so funny because we we’re just talking about this last night. You know, because, like, oh, I got a bit of the toilet. Oh, my god, I didn’t make it kind of thing, you know, like, from having a laugh or whatever. And it happens way more often than what we’re thinking is just like you just said, it’s not normal for that to happen, you know. And if this is happening, you can choose to get it fixed or you can put up with it exactly like what you said, hey. 

Dr Onuma

Little experiment that any of your listeners should conduct.
It’s just fascinating. One day when you’re outside in a public area and you’re sitting down right during the daytime, so maybe I get tea or coffee or chocolate or just latte, whatever it is. Just sit there and if you get a view of a public area, spend twenty minutes just observing that area just gently. And you will, at some point, see a woman that goes past and as a cough, then she’ll stop, and she’ll cross her legs, then look around, then keep moving. And you might see it in the environment. You’re having dinner. Somebody gets up to get the toilet, and all of a sudden they stop in the middle of their tracks and they cross their legs. They wait a few seconds. And if you’re confident, let me start moving again. So common. If you it’s like, you know, you it’s like hard if you’re thinking, for some reason, about a Volvo or Mercedes. Yes. We’re gonna say them. What can I mean, you start seeing them? Because you’re paying attention. Now if you have that in your mind, you’ll actually see people doing that all the time because that is what would have been due to prying and preventing themselves from leaking. 

Trish

Oh, do it all the time. I told him, which is like, oh, if I laugh or somewhere or whatever or, like, all the time. So, yep, I know that’s true. 

Dr Onuma

Layers can be good for mild stress incontinence in the vagina. I believe PRP even if you but, you know, for severe incontinence, not a good for mild. Spacing confidence, leave a PRP. Often a good option.

Trish

Yep. Awesome. Well, I’m gonna do that and then next time I’m out in town, I’m gonna go and check it out. I’m gonna say, who else does it? But just I just kinda, like, apply and and the amount of times the amount of times I haven’t made it is beyond Jake and even my kids laugh about it. And I was like, oh my god. Here she does. But anyway, it’s good to know that it can be done. It’s just whether you choose to or not. That’s absolutely true. A case of choice. I gotta say, look, thanks so much for today. It’s been absolutely fantastic. So before you go, tell us because I agree with what you said before. I reckon the Ultimate V is actually a book everybody. Everyone we should read just for the fact to understand the function and understand their own body, you know, in that not needing anything done or or wanting or whatever. It’s just a really good resource book for women. So where can people buy the Ultimate V or so you wanna labiaplasty? Give us a quick rundown. 

Dr Onuma

So in short, you can’t buy it from Amazon because it’s got too many pictures of vaginas and maybe upon it. Yeah. They wanted me to what’s some diagrams, I’m sorry. But that’s not what my interest is. So it’s self published, and you can get it through my website and my website is dronuma.com.au. Give it to you. Don’t we tell you what it is? Yeah.
I can’t tell. 

Trish

dronuma.com.au and there’s a section there that you can actually look at products and you’ll see the book come — There you go. — and I hope I do other stuff there as well.

 

Dr Onuma

That’s it. Yes. The team will respond to the product section of my website and you can get it as an ebook. Equity. You can download directly from that site. But if you want a physical copy, you can just leave us a note and we’ll post one out to you.

Trish

Wonderful. Look, thank you so much. Thank you so much for your time.

Dr Onuma

That’s great. Now you’ve been great great chatting as usual, you have a wide breadth of knowledge and an advocate for female pelvic floor health and everything.

Trish

Yeah. That’s amazing.

Dr Onuma

That’s great. It’s great, Trish. 

Trish

Thank you so much. And ladies and or or gentlemen, whatever. If you would like to go and see or check out Dr Oseka Onuma, you can just check out his website, dronuma.com.au. You’ll find a whole bunch of stuff there. Information pictures the whole lot, and he’s facing Adelaide. So which is some where I’m originally from. So thank you so much for joining us today, Dr. Onuma.

Dr Onuma

Thank you very much, Trish. You took after yourself. Great chatting.

Trish

Have a great day. Take care, ma’am. Okay. Bye. Bye.

 

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