pelvic organ prolapse: what can i do about this problem...

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Pelvic Organ Prolapse: What Can I Do About This Problem? Webcast July 27, 2010 Christina Lewicky-Gaupp, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. Joanne’s Story Andrew Schorr: Pelvic organ prolapse in women can be painful and uncomfortable, to say the least, and certainly for women who have gone through childbirth it is not an uncommon concern and for some others as well. Coming up a urogynecologist from Northwestern Memorial Hospital will explain pelvic organ prolapse, why it happens and most importantly how it can be treated. And you'll also hear the story of the successful treatment for a woman who suffered from it. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by Northwestern Memorial Hospital. I'm Andrew Schorr. Well, one of the topics that I don't know about personally but I've certainly heard about a little because of what I do is something that affects many women; certainly it's a concern for women who have gone through childbirth, and that is pelvic organ prolapse. And for women I've interviewed they say at some point they feel like maybe their insides are falling out. Now, there are a variety of approaches and it's always a concern when to do what, how aggressive, what are the options now. We're going to discuss all that with a leading urogynecologist from Northwestern Memorial, but first I'd like you to meet a woman who graciously wants to talk about it and help others understand, and that's Joanne. She's from Chicago, 63 years old now, and yes, she's had two children who are grown, I think 43 and 38 now. Is that right, Joanne? Joanne: That's correct. Andrew Schorr: So that was childbirth a long time ago. I would think pelvic organ prolapse happens earlier. When did it start to show up for you, and what were the symptoms? Joanne: It started to show up, oh, I would say around 2005, and the symptoms were relatively minor. Actually, I was told by my doctor what was going on, and it really didn't bother me and didn't change my daily life, and so nothing much was done at that point in time. Andrew Schorr: At some point, though, things got worse, and I know later in 2009, we're talking about four years later, you go for your typical women's health checkup, things are

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okay. But then things got worse. What happened? Joanne: What happened actually in the interim also was that things were deteriorating, and I had had physical therapy for about eight months and that helped. Then everything pretty much stayed the same, and then in 2009 at the beginning of September actually when I went in for my regular appointment things were stable. Within about three weeks after that the prolapse had gotten much worse. I was unable to insert my vaginal tablets, my hormone replacements. It was very, very uncomfortable, and I went in and started at that point with a pessary. Andrew Schorr: Wow. Now, obviously people have activities of daily living and many, like yourself, have a partner. You're married, of course. So I would imagine that besides other things sex can be difficult as well. Joanne: Yes, that was becoming more and more difficult, and, you know, when things become more difficult the desire goes down. Andrew Schorr: Right. Joanne: And it certainly changes your way of life. Andrew Schorr: Yeah. It's just not the quality of life you wanted. So you had this insert, if you will, that we'll hear more about. Was that working for you? Joanne: It was working in that it did hold the uterus in place. It wasn't working in that I found it just difficult in terms of cleaning, and in my opinion, it's kind of a messy device. Andrew Schorr: No fun. Joanne: Yes. And I would have to use this for the rest of my life, and that just was not something I wanted to do, so I needed to learn more about my options. Andrew Schorr: Well, our program is called Patient Power, and, Joanne, you are an example of a powerful patient. So you heard that there was an educational seminar. Joanne: That's right.

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Andrew Schorr: On this topic. Joanne: Yes. Andrew Schorr: And we're going to meet the doctor who was giving that. But what came out of that for you? Joanne: Well, I was very impressed by the presentation, and the one thing I came away with was the fact that I don't have to live like this and things can be better. And so I talked with Dr. Lewicky-Gaupp afterwards and at that point asked whether she was amenable to giving a second opinion, and she said she was, and then we kind of went from there Andrew Schorr: Yeah, I'm big on second opinions. I urge people to do that. We're going to meet Dr. Lewicky-Gaupp in just a second. Just to complete your story, though, Joanne, so you did in fact have surgery to remedy this condition in February of 2010. Now, we're recording this program, months later. How are you doing? Joanne: I'm doing great. I still have a little ways to go, but I feel like I'm about 98 percent there, and I'm very, very pleased with the result. And I do feel like I have my life back Andrew Schorr: So you feel for sure you made the right decision? Joanne: Definitely. Andrew Schorr: And your whole quality of life is back to normal. Joanne: I'd say we're almost there. Andrew Schorr: Okay. Well, let's meet the doctor who helped you. She's a urogynecologist and assistant professor in the department of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine, and of course she's at Northwestern Memorial Hospital. That's Dr. Christina Lewicky-Gaupp, who we were just talking about.

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Doctor, so first of all, it has to make you feel good here, the story of a woman who suffered for a while and then with the procedures that you can do today it really, as she said, gave her her life back. Dr. Lewicky-Gaupp: Oh, yeah. It made me feel great. That's why I went into the field that I did, to meet women like Joanne and to hopefully have a positive impact on their quality of life. What is Pelvic Organ Prolapse? Andrew Schorr: Tell us about the problem. So first of all, define it for us. What is pelvic organ prolapse? Dr. Lewicky-Gaupp: So pelvic organ prolapse refers to basically loss of support of the organs within the bones of the pelvis, so the bladder, the uterus, the vagina and the rectum. All of these organs are supported by a bowl of muscles that kind of girdle the whole pelvis and some connective tissues between the bones that hold these muscles up. And when the muscles or the connective tissues weaken with aging, with childbirth, there are other risk factors, and you can develop what would be like a hernia, and these organs then can fall down or prolapse through the opening of the vagina. Andrew Schorr: So they're sagging, but sagging so much that, as I said, some women feel their insides are coming out. Dr. Lewicky-Gaupp: That's exactly right. The degree of how far things fall down is variable from patient to patient, but most women that come to me are symptomatic because the organs have actually come to the opening of the vagina if not even beyond that. Andrew Schorr: So that affects loads of things. We talked about sex, but bladder control, even fecal control I would think too. Dr. Lewicky-Gaupp: Exactly. Women can develop pain, urinary symptoms, bowel symptoms, all of which significantly impact daily activities. Andrew Schorr: All right. Let's understand then how common this is. We mentioned about childbirth and aging, but it wasn't like somebody was jumping up and down or did too many aerobic classes, is it?

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Dr. Lewicky-Gaupp: It's a relatively common condition. The lifetime risk of undergoing surgery for prolapse for any given woman is about 11 percent. So while it's not one out of every two women certainly 11 percent is not a minority of women. What I often quote in my lectures that I do in the community is if you're a Chicago dweller you know that Soldier Field, where everybody watches the Bears play football, it's a pretty big stadium. And if you filled that stadium up about three and a half times, that's how many women undergo surgery for pelvic organ prolapse a year. So it works out to about 200,000 women in the United States each year have surgery for prolapse. When Do You Need Intervention? Andrew Schorr: Now, some women suffer for some length of time. How do you know when you're at that point where you need some intervention? We'll talk about conservative and more aggressive interventions in a second, but how do you know when you need anything? Dr. Lewicky-Gaupp: What I always tell my patients is that pelvic organ prolapse is not something that's going to hurt you or kill you or do anything bad to you, but it's going to impact your quality of life. That being said, I think quality of life is very important. Most of my patients come to me with their own stories. Some women say I used to play golf with my friends, I used to play tennis, and now I can't do it any more, and that's usually when women are seeking treatment. It's when their symptoms become bothersome and they're not able to basically do what they want to do, playing tennis or golf with the friends, even having intimate relations with their partners. Some women become embarrassed, they're uncomfortable. When to intervene is when the symptoms that you're experiencing, again, are impacting your quality of life. Andrew Schorr: Joanne, looking back on it, do you think it happened at the appropriate time, or do you think back now maybe I wish I'd done this earlier? Joanne: I think it probably happened at the appropriate time. I think I had been too accepting of some of these symptoms, and I think that's one of the things that I would really like to get out, is that the symptoms are somewhat insidious, and you just start accepting them and you think that this is the way things are going to be. So then you have one thing kind of happen and it's like a light bulb and it's like ah-ha, maybe this isn't the way it should be and I need to do something.

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Treatment Options Andrew Schorr: So, Doctor, let's talk about the treatment options. Let's start with more conservative. Joanne referred to that. Tell us where you start. Dr. Lewicky-Gaupp: Sure, that's one of the beauties, if you could say there's any beauty to this disorder, but there's all sorts of different options that range from very conservative options to more invasive, definitive management options. So Joanne mentioned physical therapy. We actually have an entire group of women here, physical therapists, that work on the pelvic floor. We are working with them in our integrative public health program. There's also the Rehabilitation Institute of Chicago here at Northwestern, and these women actually work not only to strengthen the pelvic floor with various techniques like biofeedback, there's different vaginal cones and weights, but they also kind of work with each woman individually to assess their overall pelvic health, their core strength. The list goes on. They're actually quite brilliant here. And even just doing Kegels at home, you know, ten squeezes three times a day to start, is an easy thing that can really strengthen the muscles of the pelvic floor. I offer all of the options that we're going to talk about to all of my patients because again where someone decides to start their therapy is very individual. Joanne mentioned the vaginal pessary, and that's basically a little device which is similar to a diaphragm. So it's a silicone ring, there are different shapes and sizes. Pessaries are what I say in the clinic all the time, they're like shoes, they're not one-size-fits-all, but we can fit a patient with a pessary that basically goes inside the vagina and holds everything up. Some women find that this pessary can be used for a long period of time, other women find that it's useful as a bridge to surgery. Sort of what Joanne mentioned, she used the pessary for a while but it was a little bit cumbersome and it wasn't something she wanted to do for the rest of her life. So whether or not a pessary works for someone is an individual option. And then the sort of most invasive at the same time kind of permanent solution is obviously surgery, and there are all sorts of different surgical ways and routes that we can correct the problem of pelvic organ prolapse. Andrew Schorr: Let me understand about that. So we've said in so many programs and lots of surgery programs and parts of the body, minimally invasive and this and that, and that's kind of a buzzword now. So tell us, a woman's situation is going to vary, but when you talk about different approaches help us understand that. The goal obviously is to shore everything up and support it in place. Give us some of the variations on how you might accomplish that.

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Dr. Lewicky-Gaupp: Sure. So basically the most important thing is to determine what has dropped and what's prolapsing, because anatomy tends to dictate which surgical approach is best. For example, a patient who has a dropped bladder may just require just a bladder lift, while a woman whose bladder and uterus have dropped would benefit not just from a bladder lift but also from a hysterectomy and then some sort of a suspension procedure to ensure that the vagina doesn't prolapse after the hysterectomy. So the way I think about minimally invasive surgery, there's all sorts of fancy ways we're doing surgery now, but in my mind I still think that vaginal surgery is the most minimally invasive route because we can do everything through a natural orifice, and there's no stitches on the outside. Everything is done through the vagina, and that's actually how we did Joanne's surgery. We can also fix pelvic organ prolapse through an abdominal incision, so like a bikini cut, if you will. We are also fixing prolapse through a laparoscopic route using cameras and small incisions in the belly. And finally where it's just pioneering the program here at Northwestern, fixing prolapse robotically, again with some small incisions in the belly. What's nice about Northwestern is that my partner and I are well versed in all of these routes, so again the decision of how we approach things depends on the anatomy and also what kind of lifestyle my patients lead and any other medical problems, how that might come into play as well when we decide how to fix things. Andrew Schorr: And that's one of the benefits too at Northwestern is you have a team approach. So if a woman has other situations going on you have the right people all putting their heads together too. Dr. Lewicky-Gaupp: Absolutely. In fact you mentioned the team approach. We recently opened the integrative pelvic health program here at Northwestern, which is a collaborative clinic with urogynecology, colorectal surgery, urology and physical therapy. It is a center where we are all there working together because oftentimes women that have prolapse, which is what my partner Dr. Labin and I fix, might also have, for example, a prolapse of the rectum or a hemorrhoid or something that colorectal surgery is readily available and we all work together so that the patient can be seen by everyone in one visit potentially. And it's really a collaborative effort to allow women to see different specialties in one setting and kind of get everything done at the same time. Andrew Schorr: Let me understand how we get to that point. So we're trying to understand a woman's individual situation. Take us through some of the diagnostic tests you do or even I've heard there's even this Q-tip test. From the very simple to more elaborate, how do you understand what you're dealing with with that particular patient?

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Dr. Lewicky-Gaupp: Sure. Usually, as Joanne mentioned, symptoms can be somewhat insidious and develop slowly over time, although there are some studies suggesting prolapse can develop very suddenly. But generally we see women in the clinic who have had symptoms that are common to pelvic organ prolapse, for example a feeling of pressure or a bulge in the vagina that's often worse at the end of the day or after being really active. Some women complain of sitting on an egg or something larger depending on how large their prolapse is. And it's usually these kind of symptoms along with urinary symptoms, leakage of urine involuntarily, having to push inside the vagina to feel like they're emptying their bladder, or even bowel symptoms, feeling like they can't completely empty their rectum, having to really, really strain when having a bowel movement, it's usually those types of symptoms that prompt either a visit to me or potentially to their primary gynecologist who then refers the patient to me. When I see the patient we do basically a standard pelvic exam with a few tweaks to it. For example, rather than just do a speculum exam I'll often have patients bear down, push, cough really hard, pretend like they're having a baby again, god forbid, all to make sure that we see the full extent of the prolapse so that what we're seeing in the clinic is what patients are feeling at home. You mentioned the Q-tip test, that's really for urinary incontinence, which often can accompany pelvic organ prolapse, so we do bladder testing sometimes to see if the bladder is functioning okay. And it's really just a standard pelvic exam. It's not much different than what you would undergo at your regular gynecologist's office. Andrew Schorr: Would you need any imaging or ultrasound or anything like that? Dr. Lewicky-Gaupp: Generally not. What's dropped can all be kind of assessed just in the clinic. It's rare. Occasionally if a woman has had previous surgeries or other complicating factors we would get an ultrasound or an MRI, but usually all it requires is just a special exam. Andrew Schorr: Now, I talked about this being an effect for many women of childbirth, but was it that they had a particularly big baby or--in other words, what were some of the causes, childbirth and you mentioned aging, maybe there are other circumstances, too, but was it anything that they did? Dr. Lewicky-Gaupp: Oh, absolutely not. Pelvic organ prolapse is not anyone's fault, and I always tell my patients, they say, oh, I shouldn't have been, you know, doing this or I shouldn't have been so active, and really there's no data to suggest that what's happened is anyone's responsibility, if you will.

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The biggest risk factors for prolapse include having babies vaginally, especially having deliveries where forceps had to be used or some sort of other operative delivery. Those kind of difficult deliveries, bigger babies, just tend to injure those muscles that I mentioned earlier that hold up all the organs. There are certain chronic conditions where there's increased pressure that's placed on the pelvic organs. So for example, I do see women who are mail carriers and have been mail carriers for decades, and they develop prolapse from heavy lifting. Chronic constipation, for example, is another one. So those are a few things that potentially could be modifiable, but again everybody lives their life and does what they do. The good news is that this is all fixable. Andrew Schorr: You mentioned about aging. So my 87-year-old aunt I think had this problem. So first of all is that part of aging, and can someone be a surgical candidate even at advanced age? Dr. Lewicky-Gaupp: The answer to can someone be a surgical candidate at the age of 87, absolutely. Certainly we would investigate any other comorbid medical conditions that the patient had, we can absolutely perform surgery on someone who is 87. The 87, did you say your grandmother or was it mother? Andrew Schorr: It was my aunt, but I was just wondering or even as somebody gets older. Joanne is 63, that's sort of the new 53 now. Dr. Lewicky-Gaupp: Absolutely. Andrew Schorr: Or 43, I'd like to say, but at any rate as someone gets older I imagine then also you don't have the muscle tone, so that can lead to the cause there too, right? Dr. Lewicky-Gaupp: Correct. And prolapse generally does affect women after their childbearing years and around menopause, but at the same time women of all ages can develop pelvic organ prolapse. So someone who is 39 but has had three babies between the ages of 25 and 35 can certainly develop prolapse as well. Andrew Schorr: Let me understand what tools you have. You mentioned the many different ways of the surgical approach. What about the materials and other things you used to shore things up. Are we getting better, is technology getting better so that it can be more lasting? Dr. Lewicky-Gaupp: The answer to that is yes and no. Generally, here at Northwestern there's this new fad out in the community, and I think some people are putting in different meshes

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inside the vagina, but I think the research is going to show that using native tissue and not putting any artificial material in the vagina is actually the best way to do this surgery, and that's what we do here at Northwestern. We don't use any vaginal mesh kits. We actually shore things up, to use your language, Andrew, to ligaments within the bones of the pelvis that everyone has. These are permanent structures, your own structures, and we basically can suture the vagina, whatever organs are dropped and reinforce the connective tissue just using the patient's own tissue. So we do not generally do vaginal mesh kits. One of our abdominal procedures involves placement of a mesh inside the belly, and that type of mesh we do use, and again it would be an individual decision based on the patient's history and kind of what's prolapsing, but that's the one mesh that we do use that has over decades proven to be very effective without complications. Andrew Schorr: You used a word I want to explore a little, "fad." And that happens sometimes even now we see in surgical approaches. We talked about the number of women who may need this procedure. Joanne, you said you got a second opinion. Would you recommend that for women, even if that means seeing two surgeons because we hear different people have different experience, not everybody has a team, not everybody specializes in this and they take different approaches. What would you say? Joanne: I would definitely say to get a second opinion and even a third one if you are still uncomfortable with the two people you talked with. I believe that one of the most important things is finding a doctor that you are really comfortable with and that you feel like you are getting the answers that you need to have and that they're taking the time with you. Andrew Schorr: Dr. Lewicky-Gaupp, let me understand this now about second opinions. Sometimes, especially if you haven't been around the doctor or certainly had surgery before, you feel a little uncomfortable. I don't want to upset the first doctor I saw, and I feel a little awkward saying I want to get a second opinion. How do you feel about if somebody said that to you, or if somebody came to you for a second or even a third opinion? Dr. Lewicky-Gaupp: Oh, I absolutely agree with Joanne. I see a lot of patients for second opinions, women that have seen their community physicians and then they come to Northwestern because it is a tertiary care center. So not only do I see a lot of women for a second opinion I always encourage my patients to get second opinions if they have any questions, if they have any concerns. Because like Joanne said while most of the surgery that we do can be done in a very minimally invasive way

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and women recover very quickly, it still is a major surgery. Even, as Joanne said, she's five months out but she's still not 100 percent. She's 98 percent, and I'll take that any day, but this is a big decision, and I think it's very important that you talk to as many people as you need to to make that decision, especially the leap to surgery. Andrew Schorr: Let's help women understand they need to make an informed decision. Joanne, I know you had some bladder issues for a few days right afterwards, and that involved some self cathing. Women can react to surgery, recover differently and it takes a while. Doctor, what would you like women to know just to understand the risks of surgery and this surgery? Dr. Lewicky-Gaupp: What I talked with Joanne about beforehand, we try to cover as many possibilities of things to expect. The beauty of Joanne's surgery, for example, which was all done vaginally is that you feel really great really fast. The problem is that then your expectations are such that when there's a little tweak or the bladder starts acting up a little bit it's really a bummer, because you feel so good otherwise. So what I tell my patients is that within a few weeks you'll be back to yourself, but the body actually needs about three months to fully heal, and even after that for the first six months you may not have the same amount of energy you had before the surgery. Your body needs a break. What Joanne developed was the irritable bladder, so that's one of the risks of surgery. When you operate near the bladder, around the bladder, the bladder can start acting up afterward. Usually it's only for a few days, maybe a week or two, and then the bladder calms down, but that's something that we need to inform our patients about. Andrew Schorr: And with any surgery there's always a slight risk of infection, and so you're always guarding about that. So you have to go into it with your eyes open. But I guess when we put it all together, Doctor, a woman in discussions with you or another specialist will get to the point where does this make sense for me to have what can be a permanent solution, right? This surgery can be lasting. Dr. Lewicky-Gaupp: Absolutely, and the beauty of all the choices that women have is such that you can always start like Joanne did with a pessary. You don't have to come in and have surgery to fix this problem. You can always start with more conservative measures, physical therapy, the pessary, doing Kegels, before ultimately opting to surgery. Or women might find that they're happy just with the more conservative measures and that their symptoms improved significantly and they don't need to have surgery. It's all a decision that I make individually, and it's really, really up to the patient depending again on how much this is impacting her quality of life.

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One thing I should mention too is that surgery is not a hundred percent. There's always a risk of recurrent prolapse. Studies have shown that about 10 to 20 percent of women over the course of their lifetime may develop a recurrent prolapse, so that's something to consider as well. Generally, if a woman does develop recurrent prolapse it's much less symptomatic and a very small prolapse, but still that's something I counsel my patients about as well. Nothing in life is a hundred percent. Andrew Schorr: Right. One last question about that, if that happened to a woman could she be a candidate for a revision surgery to try to correct that remaining problem? Dr. Lewicky-Gaupp: Absolutely, and again sometimes that recurrent prolapse is something that--my patient comes back to the clinic five years after that surgery and we look and the bladder has settled a little bit. And my patient will say to me, what, I didn't realize that, I feel great, and that's not something we need to fix then. It's really again the patient who comes in and says, you know, Doctor, I feel like my bulge might be coming back again and it's bothering me. That's the patient that we would opt for potentially doing another surgery or again trying more conservative measures first. Andrew Schorr: Well, thank you so much for explaining this, Dr. Christina Lewicky-Gaupp, and your specialty is doing this with your partner and then the whole team with you at Northwestern. And sounds like a great center to offer women all the options. Thanks for explaining this to us. I wanted to just give the last word to Joanne MacDonald. So, Joanne, you've been listening but of course you've lived it. There is a woman listening for herself or a friend, maybe in the middle of the night where this is bugging them. What would you say to guide them in trying to make a decision knowing that people's situation varies? Joanne: I guess the first thing I would say is not to be too accepting of the symptoms and thinking that you have to live with them and start by gathering as much information as you possibly can through reading or--I'm very fortunate. Where I live I have an opportunity to hear many presentations, and that's pretty much how I got tied in into this whole thing. And then find the physician, as I said before, that you're very, very comfortable with and that you can start bouncing off all these various questions that you have. And talk to more than one person. And as far as the surgery, I did have a very easy surgery, and my recovery had a few blips, but, you know, everything in life has got some challenges. They were not anything that couldn't be overcome, and I am very, very happy with the results. I couldn't ask for anything more, and I really do feel about ten years younger.

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Andrew Schorr: Wow. Okay. So we have to introduce you next time as Joanne MacDonald, 53 years old. Joanne: I think that sounds great. Andrew Schorr: There you go. Thank you both for being with us and helping people really around the globe understand and also the perspective of you, Dr. Lewicky-Gaupp, what you're doing at Northwestern. We really appreciate your dedication and thanks for coming out of the operating room to help us understand. This is what we do on Patient Power time after time. We have a vast library on the nmh.org website. Wherever you hear this, we're happy to bring this expertise and the inspiring story of people like Joanne MacDonald. I'm Andrew Schorr. Thanks for joining us. Remember, knowledge can be the best medicine of all. For more information or to schedule an appointment with a Northwestern Memorial physician, please contact our Physician Referral Service at 1-877-926-4664 or visit us online at www.nmh.org. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

pelvic organ prolapse: what can i do about this problem...

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