SECOND OPINION | Pelvic Organ Prolapse | APT | Full Episode

SECOND OPINION | Pelvic Organ Prolapse | APT | Full Episode


(ANNOUNCER)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association,
an association of independent, locally operated, and community based Blue Cross and Blue Shield
Companies, supporting solutions that make safe, quality, affordable healthcare available
to all Americans. Second Opinion is produced in association
with the University of Rochester Medical Center, Rochester, New York. (MUSIC) (DR. PETER SALGO)
Welcome to Second Opinion where you get to see firsthand how some of the country’s
leading healthcare professionals tackle health issues that are important to you. Now, each week, our studio guests are put
on the spot with medical cases based on real life experiences. By the end of the program, you’ll learn
the outcome of this week’s case and you’ll be better able to take charge of your own
healthcare. I’m your host, Dr. Peter Salgo, and today,
our panel includes, Dr. Gunhilde Buchsbaum from the University of Rochester Medical Center;
special guest, Sherrie Palm; physical therapist, Dr. Wendy Featherstone; Dr. Victoria Handa
from Johns Hopkins; and our Second Opinion primary care special physician, Dr. Lou Papa
from the University of Rochester Medical Center. Our case today concerns Lisa. She’s a 44 year old woman, a daycare worker,
married with two children of 18 and 15 years. She’s in her primary care physician’s
office now for a routine medical follow up. After discussing the results of all of her
lab work, all of which by the way, were normal, so no need to go further with that, except
for her thyroid test. She’s known to have some thyroid issues. Her PCP adjusted her thyroid dose and asked
her if there is anything else she would like to talk about. Her reply was, “Nope. Everything’s fine.” Is this common? (DR. LOU PAPA)
Yeah, it’s common. If you have a young healthy person, it’s
not unusual that they don’t bring anything up, that’s why very often we’ll ask to
review a systems questions. (DR. PETER SALGO)
Review of systems is? (DR. LOU PAPA)
Review of systems is a way of prodding the patient’s memory a little bit. So, we usually go over the different systems
in the body. Neurologic system, cardiovascular system,
asking them about specific symptoms they have been experiencing that are bothersome or affecting
their quality of life. Some stuff, patients don’t want to talk
about. (DR. PETER SALGO)
I read ahead in the chart a little bit and I happen to know that she’s not telling
her primary care physician something very important. She’s been feeling pelvic pressure and she’s
been having trouble keeping a tampon in place and further, she’s disturbed because she
and her husband have been drifting apart. She’s been having pain during sexual intercourse
and so they haven’t been engaging in sexual intercourse, so they haven’t been engaging
in sexual intercourse. Does it surprise you that she didn’t share
this? (DR. LOU PAPA)
Unfortunately, no, it doesn’t surprise me. Those are very sensitive topics for both men
and women and very well depends on trying to tease it out a little bit. (DR. PETER SALGO)
But I mean, it’s a doctor’s office. If there’s any place you’re supposed to
deal with this, isn’t it your office? (DR. LOU PAPA)
It is, but I mean if you can imagine just talking about those sorts of things are embarrassing. In some respects, your primary care doctor,
you have a long term relationship, you know, people don’t even talk to their family members
about this stuff and sometimes, the primary care doctor is almost like a family member. They are just embarrassed in talking about
it, especially if it’s affecting the relationship of the spouse. (DR. PETER SALGO)
Well, two years go by after this doctor visit, during which she shared none of that information
and now, she’s in her obstetrician’s office and she’s been experiencing lower back pain,
pelvic pulling and she often feels that when she’s sitting, she’s sitting on a ball. She’s terrified, she says, because she also
has noticed something sticking out of her vaginal area. So, we’ll broaden this discussion to everybody
on the panel. What’s going on here? (DR. GUNHILDE BUCHSBAUM)
She has pelvic organ prolapse. (DR. PETER SALGO)
You think its prolapse? What is that? (DR. GUNHILDE BUCHSBAUM)
Prolapse is when the pelvic organs, which include the uterus, bladder and vagina, are
sagging from their normal anatomical position. The most common symptom that a woman experiences
with pelvic organ prolapse is feeling a bulge from her vagina, often when they are wiping
themselves or washing themselves. (DR. PETER SALGO)
So, this is a common presentation that they are experiencing. What holds the pelvic organs in place? (DR. GUNHILDE BUCHSBAUM)
Well, connective tissue of all types. The vagina by in large is suspended sideways
in front, back and towards the top by various connective tissue structures. In addition, the pelvic flow muscles give
support to the pelvic structures. (DR. PETER SALGO)
So, these pelvic organs are held in place by structures and you get a model to show
us exactly what we’re talking about here. (DR. WENDY FEATHERSTONE)
Yes, the pelvic floor muscles run from the pubic bone in the front and back to the tailbone. They’re kind of like a hammock or a sling
that helps support the pelvic organs. They’re also helped by some of the hip muscles
from the side and are part of the core muscles, which many people think are just abdominal
muscles. So, in terms of back pain, you think of this
as sort of a functional unit. You have the pelvic floor and the core muscles
there. (DR. PETER SALGO)
So, in terms of this prolapse that we’ve been talking about, is it fair to say that
the muscles aren’t doing what they’re supposed to be doing here? (DR. GUNHILDE BUCHSBAUM)
I don’t think we can isolate the muscles or the connective tissue at just the one structure. They work as a unit. (DR. PETER SALGO)
Alright, well Sherry, you’ve experienced this problem. Tell me your story. (SHERRIE PALM)
Well, for me, the tissue of the vagina was what I noticed first. Now, backdrop for me, I’ve been digging
into health issues of all different types for 25+ years. My best friend is my health care practitioner,
so we had discussed all kinds of health issues on an ongoing basis, which made it even more
startling to me to find out when I went in to find out what that bulge of tissue was
that it was pelvis organ prolapse, something I’d never heard of. I had one vaginal delivery and I was 35 when
I gave birth to my son and there were no complications. He was 6 lbs. 11 oz., so he wasn’t a large
baby. I have MS and so I have a pre-disposition
to muscle weakness. I don’t have any problems with it. I’ve been very aggressive with my own regimen
to keep that under control. I am an aggressive exercise person and no
idea that I really had to be concerned about pelvic organs. I did have a hysterectomy and that was a vaginal
or abdominal incision. No complications from that, so one of the
things that probably compounded my personal situation was that I’m very aggressive with
my landscaping and we have large boulders and when the front end loader wouldn’t push
the boulders where I wanted them, I would use my body strength. (DR. PETER SALGO)
Can I just stop you for a minute? You had this big machine, this front end loader,
it didn’t work, you were going to push it? Is this a typical story, by the way, of someone
pelvic organ prolapse? (DR. VICTORIA HANDA)
Yeah, I would say that a lot of aspects of your story are typical and a lot of times,
I don’t know how you felt, but a lot of times people notice something that looks like
a lump and their first thought is that it’s cancer, they have a tumor. So, sometimes people are really concerned
on that basis before they find out what the cause is. (SHERRIE PALM)
That is where my thoughts went when I felt the bulge. I probably felt the bulge for about two months
before I actually got a handheld mirror out and took a look to see. (DR. PETER SALGO)
Why did you take that long? Were you frightened? (SHERRIE PALM)
No, I wasn’t frightened at all; I just work a lot of hours. I was busy, you go in, you go to the bathroom
and then you get on with your day. So, when I finally thought, “What is that
down there?” I got the mirror out and I looked and I thought,
okay, this can’t be good. It wasn’t painful. I just knew it had to be explored and I had
to find out what it was. (DR. PETER SALGO)
Okay, so we have a woman whose had some pelvic surgery, who’s had childbirth, vaginal delivery,
does this tell you, is this the cause of pelvic organ prolapse? Can you point to those things and say, “That’s
what did it!” (DR. GUNHILDE BUCHSBAUM)
No we can’t. (DR. PETER SALGO)
Why not? (DR. GUNHILDE BUCHSBAUM)
Because we know there are women who have had any children and they will have pelvic prolapse. We know women who had six, seven or eight
childrens, big ones on top of that, and they don’t have any pelvic organ prolapse at
all. So, it seems that there is a pre-disposition
that is biological towards prolapse. When you have that, there might be additional
damage or this might be worsened by giving birth. (DR. PETER SALGO)
I’m going to tell you about Lisa. Lisa has had two babies, one 9 lbs. 7 oz.,
the other 8 lbs. 5 oz., both were delivered vaginally. The first was delivered with the use of a
vacuum extraction, which I am going to simply suspect is a bit more traumatic than a non-vacuum
extraction. She is 20 pounds over her ideal weight, she
never smoked, she’s experienced occasional stress incontinence for the past fifteen years
and she’s been noticing it more and more recently, this prolapse, when she lifts kids
at the daycare center where she works. Any of these things sound like a risk factor? (DR. VICTORIA HANDA)
There’s a lot of things in there that could be a risk factor, I mean I definitely agree
with Gunhilda that there’s probably some inherent biological pre-disposition that some
women have towards this problem, exactly what that is, we need to find that out. I would disagree a little bit because I think
child birth is a very powerful risk factor. There is no question that there are women
that have not given birth who develop prolapse regardless, but having had a vaginal delivery
is a huge risk factor, but I think a little bit more problematic and controversial are
some of the other things you mentioned. Obesity, not clear that that’s a risk factor,
may be, and I think that even the heavy lifting is a little bit controversial. (DR. LOU PAPA)
It’s just like any other disease, there are certain risk factors that are very strong
and some that are not quite so strong, but there are individuals that have heart disease
that do all of the right things and don’t have any of the risk factors. (DR. PETER SALGO)
Okay. Wendy, what about Kegal exercises? Would they have helped? (DR. WENDY FEATHERSTONE)
A lot of that depends upon the degree of the prolapse. With a milder prolapse, less bulging out,
you can use exercises to help reduce the symptoms. Now it doesn’t repair the connective tissue
that Gunhilda was speaking of, so if we think about it, it’s not just the Kegal exercises,
it’s not just the pelvic floor because you want to think also, in Lisa’s case, about
what she does during the course of the day. You want to look at her posture. We look at alignment things as physical therapists. How do you keep the rib cage lifted off of
those organs? How we’re using the muscles that work with
your pelvic floor/? Your pelvic floor is part of the core, as
I mentioned a little while ago and it works with the deepest layer of your abdominal muscles. So, if you’ve got some muscles, some of
the bigger abdominal muscles, have the capacity to actually fold you forward and push downward. It’s a balance of or a coordination of these
muscles that we’re looking for. Other things, in Lisa’s particular case
is her lifting. We take a look at how are you lifting? Are you bending over and straining to lift
the children in your daycare, and taking a look at teaching her proper body mechanics,
how can you avoid pushing down from above, as well as let’s lift up from below and
around, and get good postural support. (DR. PETER SALGO)
Well, the doctor does a pelvic exam on Lisa and finds that she as a prolapsing cystocele. What’s that? (DR. GUNHILDE BUCHSBAUM)
So, the bladder rests on the top part of the vagina and when that starts sagging, it is
called a cystocele as opposed to when the back part is sagging, or the support is weakened
and the rectum starts bulging, that is a recto seal. (DR. PETER SALGO)
So, there are different kinds of prolapse. Do they all have the same symptoms? (DR. GUNHILDE BUCHSBAUM)
They have some in common, a bulge is a bulge. Just when somebody feels a bulge, it means
to me there is a prolapse, but I couldn’t tell from a bulge what that bulge is. (DR. PETER SALGO)
Are these symptoms that women experience life altering? (DR. GUNHILDE BUCHSBAUM)
Some can be. Some women have no symptoms at all, some women
have mild symptoms only, others might not be able to void, some women have to push back
the prolapse in order to urinate or to move their bowel. Some women have pain. (DR. PETER SALGO)
Okay. What about with you? Did it alter your life? (SHERRIE PALM)
I’m one of the fortunate ones that did not have pain with my prolapse. The thing that impacted me the most, I would
say, was I was a grade three. I had three types of POP out of the five types. In a more advanced stage, it’s not an incontinence
issue which is very common in the earlier stages. Its urine retention, you can’t get the pee
to come out. That was the part that impacted me the most. (DR. PETER SALGO)
Wendy, you see women with this problem, what’s the most common complaint you see? (DR. WENDY FEATHERSTONE)
They do come to me with the complaint of the bulge. Usually it’s worse as the day wears on. They get to where they don’t want to stand
towards the end of the day. It’s kind of a fatigue factor by the end
of the day. Difficulty lifting and intercourse can be
a problem too, symptomatically. (DR. PETER SALGO)
Well, Lisa, she says, “Doc, did the size of my babies and my difficult labor cause
my problem?” And your answer would be? (DR. GUNHILDE BUCHSBAUM)
I don’t know. (DR. WENDY FEATHERSTONE)
I don’t know. (DR. PETER SALGO)
Great. I’m sure Lisa was really happy hearing that. Would this have happened, she asks, if I had
had a cesarean section? (DR. GUNHILDE BUCHSBAUM)
Maybe. (DR. PETER SALGO)
Oh, this is even more definitive. And your answer would be? (DR. VICTORIA HANDA)
Well, we’ve just finished some research at Johns Hopkins to essentially look at that
question. The question is how much less risk do women
face regarding prolapse if they have a cesarean delivery? Our data suggests, now it’s hard to say
that this is the cause and effect, but for every seven vaginal births, there would be
another case of prolapse, so hopefully that would put it into context in terms of the
risk. (DR. PETER SALGO)
Let’s talk about the overall incidents? How common is this problem? (DR. GUNHILDE BUCHSBAUM)
That is hard to say definitively because we just said; this is something that is not really
talked about. (DR. PETER SALGO)
Okay. Most women who experience this problem are
post-menopausal. (SHERRIE PALM)
I beg to differ with that. (DR. PETER SALGO)
The numbers don’t support that? (SHERRIE PALM)
I speak with women every day and you read over and over that it’s women over 50 and
I’m sure it’s the same for all of you ladies. I speak with women every day in their 20’s,
late 20’s and up, the youngest one that I’ve spoken with is 21 years old, has never
given vaginal birth and never even given birth at all, a gymnast. (DR. VICTORIA HANDA)
I believe the average age for surgery is 50. (DR. PETER SALGO)
its 50? So it’s peri-menopausal? I guess they don’t come to surgery without
some symptoms persisting for some time and that common conception is wrong as well. So far, we’re just debunking everything
about POP (Pelvic Organ Prolapse). After the doctor told Lisa that she had pelvic
organ prolapse, Lisa said, “What on earth is that?” So, why does it seem that women are finding
out what POP is only after they are diagnosed? Why don’t more women know about it up front? (DR. LOU PAPA)
Well, it’s probably the classic situation where they’re kind of suffering in silence. A lot of times, if I find out about it, it’s
because I’m doing a pelvic examination for some reason and they’ll say, “Oh yeah,
that’s been there for years.” (SHERRIE PALM)
These are topics that women aren’t comfortable talking to their doctors about. They can’t even talk to their husbands about
this stuff. Everyone thinks that urinary incontinence
stands alone, it’s a disease and it’s not, it’s a symptom. So, then you add in incontinence and if you
add in the pain with intercourse and the tissues on your vagina. Women that I speak with that are shying away
from sex because of the symptoms and let me ask the men on the panel here. If your, the woman in your life, and you have
had a healthy intimate relationship with her for “x” number of years, suddenly stopped
being intimate with you. Would it occur to either of you that there
was a health condition related to that or would you jump right to the whole, “Either
she’s not into me anymore or she doesn’t enjoy sex anymore page.” (DR. PETER SALGO)
Lou, you can handle this one first. (DR. LOU PAPA)
Well, it’s kind of unfair because I have a medical background, so I would be concerned
to some respect that if it’s suddenly stopped like that then it would be a medical cause,
or there’s something physiological or depression or something like that would be raising that,
but I would agree with you that if that happened in some other instance without that kind of
hook in knowing that it probably would create a lot of tension. (DR. PETER SALGO)
Okay, I would like to pause for just a minute and sum up where we are. Pelvic organ prolapse is a condition that
occurs when the normal support of a vagina is lost. The result of which is that the pelvic organs
and the tissues sag downwards. The symptoms often create a scenario of embarrassment,
as well as discomfort, patients often don’t talk about it and as a result, a lot of women
don’t even know about it. (DR. LOU PAPA)
I think it’s important, like any of this kind of “taboo” topics that nobody wants
to talk about, there’s always a concern that it could be something more serious. I know a newer degenerative disorder comes
into mind. There’s a collection of abdominal sidings
or masks that could be growing that could be exasperating the problem, so it is something
that warrants investigation. There is some danger in not reporting it. (DR. PETER SALGO)
Alright, well we started off this broadcast talking about Lisa, who’s been experiencing
pelvic organ prolapse and sharing her story with us is Sherry. Lisa is referred by her obstetrician to a
uro-gynecologist. What’s going to happen there? (DR. GUNHILDE BUCHSBAUM)
First we take a history, so I ask her how she is aware of it. I ask her whether she has any problems emptying
her bladder, whether she’s experiencing urinary urgency, whether she needs to use
her finger in order to evacuate her bowel, whether she has any other symptoms. (DR. PETER SALGO)
These are very embarrassing questions. (DR. GUNHILDE BUCHSBAUM)
That is true. It is very important that as a physician,
you make your patients feel comfortable to answer these questions. (DR. PETER SALGO)
Alright, well Lisa has been diagnosed with a cystocele, what are her treatment options? Surgical, non-surgical, help me out with this. (DR. VICTORIA HANDA)
Well, other than the physical therapy, another non-surgical option to consider would be a
pessary. (DR. PETER SALGO)
What is a pessary? (DR. VICTORIA HANDA)
A pessary is a device that goes in the vagina, the woman can put it in herself and take it
out in most cases, and it basically just supports the walls by holding up on the walls. Pessary isn’t necessarily the answer for
every woman with prolapse. Some women, depending upon their anatomy,
might find a pessary uncomfortable. It may not stay in position well. If women are motivated to try a peccary, it’s
worth a try in case it’s the perfect solution for them. (DR. PETER SALGO)
The surgical options are what? (DR. GUNHILDE BUCHSBAUM)
Well, for the cystocele right now, again, surgery depends very much on what the exact
defective prolapse is. Now in my opinion, I rarely see the cystocele
all by itself. Most of the time, a cystocele comes together
with a dropping or a sagging of the uterus. So, most women who undergo a surgical repair
for a cystocele need some kind of support of the top of the vagina, also. (DR. PETER SALGO)
Sherry, what course of treatment did you pick? (SHERRIE PALM)
Well, initially, I tried the peccary, that was the second term that I got from my physician
that I’d never heard of before and I tried it for a couple of weeks and I’m lucky the
second one she fitted me fit great. I had no discomfort. I learned the insertion/removal quickly, however;
after two weeks of utilizing the pessary, I knew it wasn’t going to work for me because
it’s just one more thing to do. When you’re a busy person, when you’re
a busy woman and you’ve got to do all of the other things in your life that you’ve
got to care of, this was one more thing to stack on top of it and I just didn’t want
to deal with it, so I shipped it to surgery. (DR. PETER SALGO)
Well, Lisa tried the pessary and in fact it worked for her for two years, but two years
later, which is where we are now, she’s back to see her uro-gynecologist, she says
that she just can’t find the time to do the peccary. She’s supposed to do the Kegal exercises,
but she can’t do them. Although she’s happy with peccary, she wants
a more permanent fix. After examination, her doctor finds that her
prolapse is worse, so Lisa wants surgery. If she has the surgery, will she be fixed? (DR. GUNHILDE BUCHSBAUM)
Potentially. Again, I tell my patients that the greatest
risk of surgery for prolapse is occurrence for prolapse. That’s the number one risk. How big that risk is between ten and thirty
percent and forty percent, it depends. Also, if we fix what is broken now, that is
no guarantee that something else that is not broken now will not break later. This is sort of a weakness of the support
tissue of the vagina and often is something is weak, everything around it might be weak,
too. (DR. PETER SALGO)
That being said, let’s stop for a minute and sum up what we’ve discussed so far and
then we’ll continue on again. Management for pelvic organ prolapse may be
exercise or it may be devices or it may be surgery. The course of treatment depends not only on
the anatomy and the severity of the condition, but on the individual as well. It is important to know that no matter what,
there is something that can be done to improve the condition. This is not a hopeless case. There is lots of opportunity for treatment
out there. Well, Lisa’s happy. After having the surgery, she has no longer
had her tissue bulging out, but she was surprised to find that her bouts of stress incontinence
did not go away and she is still experiencing painful intercourse, so the surgery didn’t
fix everything. Why not? (DR. VICTORIA HANDA)
Well, I think, like Sherry said earlier, sometimes incontinence and prolapse are related and
sometimes they’re unrelated. Typically, it’s not that uncommon that they’re
seen in the same patient, so I would typically assess a woman for incontinence if she was
presenting with prolapse, so they could both be addressed at the same time, but a treatment
for prolapse won’t typically cure incontinence. The one that’s a little harder, though,
is about the discomfort with sexual activity. Some of the symptoms we’ve been talking
about are not specific to prolapse, so discomfort with sexual activity, back pain, there’s
been some other things that have come up that may or may not be related to prolapse at all. (DR. PETER SALGO)
Going forward in terms of her physical activity, what she can do to help herself, what do you
recommend for her? (DR. WENDY FEATHERSTONE)
Well, as Gunhilde mentioned, the chance of this recurring is a problem and so doing exercise
in adjunct to the surgery is, you know, the surgery isn’t the quick fix. So, to have her say, “Didn’t have time
for the Kegals. Couldn’t do them.” You know, you have to make time, its maintenance;
it’s what you’re going to have to do. Then thinking about, okay, so what else might
be helpful there strengthening wise, she’s lifting kids all day. Very often with surgeries, there’s a lifting
restriction for a period of time, but my opinion, when you’re strengthening, you’re actually
going to prevent strain, so the stronger you are, you lift that kid up, you can do it,
then you aren’t straining and pushing down and pushing out your organs. So, you really want, you know, good muscular
strength throughout the body as a preventative, as an adjunct to the surgery, so I think she’s
just going to have to find the time for that. (DR. LOU PAPA)
The therapy that is prescribed is like another prescription. It’s like saying you don’t have time to
take your blood pressure medication. A lot of surgical procedures, joint replacement,
cardiac surgery, the trip up in recovery very often is falling behind on the therapy. (DR. PETER SALGO)
Sherry, how you doing? (SHERRIE PALM)
I’m doing great. I’m a big believer in maintenance. If you want to maintain the best quality of
life, you have to do maintenance and whatever form works for you, so the Kegals are so important
and I’ll be doing those until I’m dead. As far as I’m concerned, the most important
thing we can do is to create the recognition of this health issue and let women know that
there’s no stigma tied to POP, no matter what symptom you’re experiencing. Once we get the symptoms on the table, everybody
starts talking about them; it’s going to be the same path as what happened with erectile
dysfunction twenty years ago. Nobody talked about it twenty years ago, now
it’s on prime time TV. So, the same thing needs to happen with this. Once women are familiar with this condition,
they know what the symptoms are, they’ll recognize those symptoms in themselves, and
they’ll go to their physicians and they won’t be so embarrassed to ask the right
questions and get the help that they need. (DR. PETER SALGO)
That is all the time we have for this broadcast. Thank you so much for coming, thank you all. We are out of time, but you can continue this
conversation on our website secondopinion/tv.org, where you’ll find transcripts, videos and
more about pelvic organ prolapse and other healthcare topics. Again, thank you for watching, thank all of
you for being here, especially you, and I’m Dr. Peter Salgo, and I’ll see you again
next time for another Second Opinion. (ANNOUNCER)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association,
an association of independent, locally operated, and community based Blue Cross and Blue Shield
Companies, supporting solutions that make safe, quality, affordable healthcare available
to all Americans. Second Opinion is produced in association
with the University of Rochester Medical Center, Rochester, New York.

2 Comments

  • Sherrie Palm says:

    Quality educational programs on pelvic organ prolapse like this segment by Second Opinion help initiate a change in recognition for an extremely common women's health concern that sadly remains in the closet despite being on medical record for over 3000 years. We need to get to the page where women no longer hide their symptoms in embarrassment and freely approach their health care practitioners for advice and guidance.

  • Deb C says:

    I am glad POP & SUI problems are more openly being discussed. They need to be addressed, but please use surgery as a last resort. If surgery is warranted, consider NON-mesh repairs. FDA warnings came out in 2011 stating mesh complications are NOT rare, are very severe, often permanent, & that there is no evidence that repairs using mesh are any more effective long term then non-mesh repairs.

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