This this episode of PodMD, certified urogynaecologist and female pelvic floor reconstruction surgeon Dr Chin Yong will be discussing the topic of pelvic organ prolapse, including what pelvic organ prolapse is, how a patient would typically present, the treatment options, the likelihood of recurrence, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Chin Yong.
Dr Yong is a Certified Urogynaecologist and Female Pelvic Floor Reconstruction Surgeon who practices in both public and private hospitals. His main practice is based at Epworth Freemasons Hospital, East Melbourne. He also works at Jean Hailes East Melbourne and the Royal Women’s Hospital Pelvic Floor Unit. Dr Yong is also a member of multidisciplinary Pelvic Pain Service at Frances Perry House.
Apart from clinical appointments, Dr Yong actively involves in clinical education and research projects focusing on conservative management and native tissue surgical correction for pelvic organ prolapse. He offers minimally invasive surgery options including laparoscopic and robotic pelvic floor reconstruction.
Today, we’ll be discussing the topic of Pelvic Organ Prolapse – Dealing with the silent problem
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Chin, thanks for talking with us on PodMD today.
Chin: Thank you for having me.
The topic of today’s discussion is Pelvic Organ Prolapse – Dealing with the silent problem. Chin, Can you describe for our listeners what Pelvic Organ Prolapse is?
Chin: Pelvic organ prolapse is commonly described as the herniation of the pelvic organ through the vagina, which can be either due to the bladder, the uterus, the bowel, or all of the above. This is a non life threatening condition but can significantly affect the woman’s quality of life. It’s a very common problems. That we see tends to affect approximately one in two women following childbirth and around 40% women will have some form of symptoms.
In Australia we see approximately 19% of women will require some form of surgical intervention at some stage of their life. Yes, so so this is fairly common, but not normal. This is what I tend to tell my patients and the way we classify the prolapse, it comes into four different stages. Stage one’s is anyway coming down to the mid vagina. Stage two is when the prolapse comes to the opening approximately 1 centimetre above or below the opening. Stage three is 1cm outside the opening stage 4 means all out.
The prolapse typically affects women, as I said normally after pregnancy and childbirth, ageing and menopause is also another common risk factors as women go through the change of life, the oestrogen level becomes lower and the tissue quality can change. And typically woman who had problems earlier in their life tends to have worsened symptoms after menopause due to these changes.
A woman who have been exposed to prolonged repetitive exertion on their pelvic floor muscles, such as heavy lifting, chronic cough or constipation’s or obesity are also at increased risk of developing this problem. And last but not the least, connective tissue problems can also be another additional risk factors, although we don’t see this common commonly, such as [inaudible].
How can we identify these group of women?
Chin: Well, this is a silent problem. People don’t normally disclose this unless you start asking, from GP perspective I strongly recommend GP. Use it as an opportunistic screening whenever patient comes to visit you in your room or when or when they require a cervical screening test. It’s very common, and it’s easy for you to ask the woman whether they have any bothersome bulge or from the bladder or any bowel issues that that is bothering them.
And and all, all you need to do is to ask those simple questions to capture this group of women, because they would not disclose the problem until you ask them and most women will consider this as a as a normal problem and hence they may not find it an issue unless you ask them and there’s always something can be done about it.
How would a patient with pelvic organ prolapse typically present?
Chin: So the most common presentation is usually a long sitting in the vagina, either in the form of bulge or heaviness. And as I alluded in my previous question, typically when patient comes to see a doctor or seek help, they will have at least a stage two prolapse, meaning something at the opening. They can also experience painful sex, particularly during penetration or their partner felt some form of obstruction during penetration.
They can also present with a bladder symptoms, such as urinary urgency, frequency, or even incontinence, trouble emptying the bladder or recurrent bladder infections. They can also come with bowel problems such as trouble in emptying their bowels, needing to use their fingers to reduce the bulge to assist with a bowel emptying. And very occasionally they get a bit of accidents from the bowel, which can also happen concurrently with other prolapse issues such as the rectal prolapse.
What are the treatment options?
Chin: So, so the way I divide this management options are divided into the surgical, non-surgical and surgical management. Inn terms of non-surgical management, the first line of treatment as the American College of Obstetricians and Gynaecologists are recommended, vaginal pessary is the first line of management for treatment of pelvic organ prolapse. There are different sizes and shapes. Uh, that I offered to patients the successful pessary uses is typically around 50%. Uh, so it’s a matter of trial and error and and pretty much most women will declare themselves whether this management option is suitable for them or not. And there is also an option for pessary self-care. For some woman who have who wishes to have a better control in this in their own care.
Conservative management with pelvic floor physiotherapy’s is also another important management, basically to rehab their pelvic floor muscles following a childbirth injury or any surgical intervention. This will not reverse any structural problems, but will only control the prolapse symptoms, I.e. the heaviness or the bulge sensation? And these two can be used in combination with the vaginal pessaries and some pelvic floor physiotherapy’s they do manage vaginal pessaries in the community, so did this is an important first line management before proceeding to surgical management.
However, there was another group of patients that are not responding to the conservative measures and therefore surgical management will be the next step. In terms of surgical treatment there are various options available, ranging from uterine preservation, surgery or hysterectomy. The first thing that woman normally comes to me, they ask about hysterectomy as part of the treatment for the prolapse. My advice to them is that there is actually no indication to remove an organ if it’s normal and the research evidence has actually indicated that there is no difference in the prolapse outcome or recovery. In fact, those who are keeping the uterus in place tends to have lesser blood loss and shorter operating time, so it is beneficial to keep the uterus in that sense.
However, before making any decision to remove or to keep the uterus, the patient will need careful assessment by the specialist before proceeding with any further management from that perspective? On the other hand, there are some situations where the uterine conservation surgery is contraindicated, such as history of abnormal uterine bleeding, bulky large multi fibroid uterus, thicken endometrium or cancers. Recent history of high-grade cervical dysplasia or hereditary genetic disorders, such as the BRCA gene or Lynch syndrome. This group of women will certainly benefit from having a concurrent hysterectomy as part of their prolapse surgery.
In terms of the primary prolapse surgery option, I tend to offer a patient’s native tissue reconstruction surgery as a first line treatment which can be achieved by either vaginally, laparoscopic Lee or a robotic approach. As we’re all aware, most women are reluctant to have pelvic mesh due to the recent safety concerns and negative publicity surrounding the pelvic mesh use for journal mesh shoes, in particular for treatment of pelvic organ prolapse has been completely withdrawn in Australasia after losing the litigation battle due to the lack of safety data. Abdominal mesh use on the other hand, which has been described as the gold standard treatment for the uterine or post hysterectomy vaginal prolapse treatment is a great treatment option for women with the recurrent or advanced pelvic organ prolapse.
Unfortunately, no matter how successful this treatment most women still refusing to have, uh, the abdominal mesh due to the ongoing negative publicity is associated with pelvic mesh use, regardless of their effectiveness and safety data. I tend to spend more time carefully counselling my patients and offering various management options. And more importantly, to have a shared decision-making process before embarking with any form of surgical management.
Have there been any research or developments in treatment in the past years?
Chin: Yes, definitely, there are few research and ongoing research going on at the moment. We have recently completed a vaginal pessary study and we’re awaiting publications on that research data, it is a new vaginal pessary call the C-POP, it stands for conservative pelvic organ prolapse pessary. It’s made using a medical grade silicone and subjectively, patients felt having less vaginal discharge or discomfort compared to the traditional PVC ring pessary. And a lot of my patients felt it easier to manage the history due to the ease of handling the pessary and folding the pessaries prior to insertion into the vagina.
Another important potentially important change in surgical management for prolapse surgery, is the use of autologous fascial lata in for treatment of pelvic organ prolapse and incontinence for women. This this technique was developed in response to the recent mesh controversies. Basically it is a piece of tissue fascia that is harvested fom the thigh and then that get used and implanted for the prolapse surgery use. It is basically the same sort of procedure that we use for mesh procedures such as [inaudible], but we’re replacing the mesh with patients on fascia so that.
This is a very good option for women who are mesh adverse or who had previous mesh complications after some form of mesh removal or mesh surgery. This is an ongoing research study that is are being undertaken through Epworth Freemasons, East Melbourne Hospital, and there are a lot more data coming out in the next few months.
Certainly this will be potentially the new magic bullet in pelvic floor surgery in response to the mesh. As we’re seeing more women coming to the practise, not wanting to have mesh, and basically they just put offm before we even started any conversation, the first thing the patient will tell us is not wanting to have any mesh.
Are there any warning signs a GP or their patient can look out for?
Chin: What number one is when we do find that patients do have hyperparathyroidism, sometimes we do need to treat their vitamin D deficiency, at times by treating the vitamin D deficiency itself. This would resolve the hyperparathyroidism itself. And this can be done through I suppose ensuring that we checked for the vitamin D levels in the serum itself. We also should be aware that there are many other causes that causes hypercalcemia, so one of them is obviously hyperparathyroidism.
About the other causes would include haematological conditions, so these would need to be ruled out. And other malignancies such as prostate cancer can also cause hypercalcemia, especially when they have it in their advanced and they have invaded into the sacrum itself. There are other syndromes that causes hypercalcemia, and these include lytic bone syndromes such as Padgett’s disease.
What is the likelihood of recurrence of the condition?
Chin: We we know that there’s the really good published data that women who have pelvic organ prolapse or advanced prolapse stage 3 or 4, they have high recurrence rate which has been reported somewhere between 30 to 40%, in the short to long term with native tissue surgery, meaning using their own tissues with sutures only. This is not because the surgery is not good, I think the biggest factor is something to do with patients tissue quality and certainly tissue quality can change with time and other main factors that increases the prolapse recurrence include a younger age less than 60 years old, advance public organ prolapse stage three or more, eomen with wide and genital [inaudible] as a result of childbirth, and this increases further if they have four or more. Or had some form of instrumental deliveries such as forseps.
Woman who had a previous hysterectomy also at increased risk of prolapse recurrence because all the important supportive structures would have been divided before removing the uterus and therefore it is important to reestablish those connection when hysterectomy is performed. However, if a woman had hysterectomy for benign reasons, normally they would not have a concurrent supportive procedures during that time, and generally they will come back at a later stage with a prolapse. So due to those risk factors of prolapse recurrence, the mesh or facia lata surgery was designed for patients who have high risk of prolapse recurrence and certainly before proceeding with any form of surgical interventions, patients need to be carefully council and made aware of the potential risk and the rationale of having a mesh or fascia lata surgery?
When should a GP refer?
Chin: There is not fast or hard rule, basically, if the GP felt that something beyond their expertise, they can start referring their patients. The general guide to GPs went refer when the patient has failed to improve with conservative management, i.e., the vaginal pessaries or pelvic floor physiotherapy’s in the community. Patients who have complex pelvic floor symptoms, such as a urinary incontinence, voiding difficulties, bowel issues and prolapse. Uh, those group of woman. I strongly recommend the GP to refer early because they will likely require a multidisciplinary team input and have a early assessment before proceeding to any further management. Women with recurrent prolapse either they had mesh or without mesh in the past is also someone that require specialist assessment in the early phase of management.
What role does the GP play in the treatment of the condition?
Chin: So the GP has a huge role in in the community, basically performing clinical assessment, basic clinical assessment, an examination at the first point of contact and refer on f they felt necessary. And it’s also important for them to start implementing the conservative measures such as lifestyle modifications, that are pertinent to pelvic organ prolapse developments such as chronic Constipation, chronic cough, Obesity, all those things can be done first in the community and also initiate a referral to pelvic floor physiotherapy’s.
I strongly recommend the GP to work closely with physiotherapy’s in the community And this will be a good way to start. And important for the GP to monitor for the complications as a result of prolapse such as UTI or troubles with emptying their bladder or bowels that require an escalation to the specialist care. More importantly is a coordinating the care with all the other disciplines, either in the form of urogynaecologist, physiotherapist, colorectal surgeons, some of the patient may require clinical psychologists or sexual counsellor if they have issues with intimacy.
And more importantly, I truly believe that the patients actually has a lot of trust in faith in the GP, before making any major decision in treatment, particularly before embarking with any form of surgery. Just to have someone agreeing with their decision making is important and I think patient, generally has better rapport and trust having, talking to someone that they know and giving them the reassurance that they’re making the right decision. Those are very important factors to engage the patients in the treatment gene.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on pelvic organ prolapse?
Chin: Certainly. As I alluded before prolapse is a common problem, but not normal, so we need to make sure that women understand about this and there is always something that we can treat do to treat the conditions or prevent the condition from worsening if we identify the problems early. So that goes back to the screening as well. If we pick them up early, we can implement the therapy early.
Next thing is to start the conservative therapy early in the Community and know your local pelvic floor physiotherapist. I strongly recommend working alongside with a certified pelvic floor continence physiotherapy’s and not just a routine Pilates physiotherapist, because they all have different skill sets and if you are unsure, then one thing you can do is to go onto the CFA website and search for CFA credential physiotherapist.
And finally, of course, to refer early if the patient has complex issues or they failed. The conservative management. And importantly, if you feel like it’s beyond your expertise and you’re not sure what to do, it is also an option to refer the patient on early.
Thanks for your time and the insights you’ve provided.
Chin: Thank you.