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From Incontinence to Prolapse and Back Again: the ABC's of Pelvic Floor Survivorship

They may not talk about it, but women with cancers in the pelvic region, such as cervical cancer, bladder cancer and uterine cancer, often have problems controlling their urine, bowel or flatus. Although they may feel isolated, they're far from alone.

Pelvic floor disorders do not need to cripple a woman’s quality of life. Further, surgery isn't the only solution. Many pelvic floor disorders can be successfully treated with diet modification, medication, and behavioral and physical therapy.

Listen in as Seth A. Cohen, MD discusses the ABC's of Pelvic Floor Survivorship.
From Incontinence to Prolapse and Back Again: the ABC's of Pelvic Floor Survivorship
Featured Speaker:
Seth A. Cohen, MD
Seth A. Cohen, M.D., joined City of Hope in 2016 as a urologist specializing in complex reconstruction of the pelvic floor, including fistula and pelvic organ prolapse repair. Dr. Cohen received his medical doctorate and Bachelor of Arts degrees at Northwestern University through the prestigious Honors Program in Medical Education, which allowed for direct matriculation into medical school after three years of undergraduate work. He completed his post-graduate training in California, including an internship in the Department of Surgery at University of California, San Francisco, a residency in urology at University of California, San Diego and a fellowship in Female Pelvic Medicine and Reconstructive Surgery at University of California, Los Angeles. Dr. Cohen has published in a variety of medical journals on topics including mesh-associated complications, robotic cystectomy and radiation exposure during lithotripsy.

Learn more about Seth A. Cohen, MD

Transcription:

Melanie Cole (Host): Women with cancers in the pelvic region such as cervical cancer, bladder cancer or uterine cancer may often have problems with incontinence and although this is sometimes difficult to discuss, it's a very important part of recovery. My guest today is Dr. Seth Cohen. He's a urogynecologist at City of Hope. Welcome to the show, Dr. Cohen. So, what type of cancers predispose a woman to incontinence and/or pelvic prolapse?

Dr. Seth Cohen (Guest): Sure, Melanie. Thanks, for having me on the show. I think it's important to note that everything you just said is exactly right. Any sort of pelvic floor malignancy, whether it's cervical cancer, uterine cancer, ovarian cancer or a non-disclosed tumor that impacts those tissue spaces, can lead to some sort of prolapse or incontinence. Really, that happens after the primary treatment for cancer. So, these are issues that tend to arise after someone has been treated for cancer, usually in the setting of some sort of surgery where tissue is removed. Now this also can occur in situations where people have had chemotherapy or radiation to that pelvic floor area because that also damages the tissues. I think it's also important to note, though, that any sort of systemic treatment for cancer, whether it's chemotherapy or radiation--any sort of systemic treatment--can really impact nerves as well and tissues in ways that we don't even know. So, any sort of cancer treatment really can ultimately result in some sort of sequelae for the pelvic floor where women might see some incontinence or prolapse.

Melanie: Women hear about pelvic floor muscles and incontinence more often in the media but what is pelvic organ prolapse? They don't seem to hear about this quite as much.

Dr. Cohen: Sure. This is probably our fault as providers. This is a terminology we use to communicate but forget that the people at large, why would they understand this? And, really, it's a hernia. That's what we're talking about. It's a hernia of the pelvic floor. The vagina, for all intents and purposes is a potential space and when tissues fall and there’s laxity in the pelvic floor, like any potential space, that area is filled. So, it's a hernia of the vaginal canal.

Melanie: So, what would that mean for the women? What would they experience if they have a hernia of the vaginal canal?

Dr. Cohen: Common symptoms for women who experience it are pressure, discomfort. Usually, they'll be walking and they often describe they almost feel like something is going to fall out of their vagina almost like a sensation of giving birth without the pain, for all intents and purposes. And, not only can it be discomforting during ambulation, it could also be discomforting during intercourse. It could be discomforting when you're doing any sort of heavy lifting; if you're at the store buying groceries. Any way that you can manifest by creating pressure in your thoracic cavity and the abdomen, that will translate down to the pelvic floor and push those tissues out.

Melanie: Are there different types of prolapse? And, are there ways to manage them that we could do without necessarily going through intervention?

Dr. Cohen: For sure. So, there are different types of prolapse and, once again, that tends to be nomenclature and terminology we use as providers to talk. But, if you imagine the vagina as three compartments: so, the anterior compartment; the apical compartment, which is the top or cap of vagina; and then, the posterior compartment. Any of those walls can fall in. So, it's like a three-walled room. At any given time, one of those walls can fall into the other and we describe that as either anterior prolapse, apical prolapse or posterior prolapse. And, really, those are pseudonyms for the structures behind those walls. So, in front of the vagina, the anterior wall, is the bladder. For the cap or the apical part of the vagina, that's the uterus and the cervix. And then, for the posterior part of the vagina, that's the rectum. When we are talking about anterior, posterior, apical prolapse, really what we're saying is, this part of the vaginal wall is falling in and most likely behind it are these other organ contents that are precipitating that. There are many ways to treat pelvical prolapse. This is not a life ending disease, thank goodness. This is a life altering disease process. If someone is at a stage in their life, if they are very elderly and they really just want to be comfortable and they are not interested in undergoing a surgical operation, there is something called a “pessary”, which is a malleable, soft piece of plastic that we insert into the vaginal canal. There are many different pessaries but the most common one looks like a disc, almost like a Frisbee and it raises or elevates those soft tissues, so that when you are ambulating or lifting, those tissues aren't herniating and falling down into the vagina. Tt works quite well. Unfortunately, a lot of women just don't want to do that because it can be uncomfortable in sexual and personal life, but for those that don't want to undergo surgery, that is certainly an option.

Melanie: And so, the pessary, is that something that once inserted, stays in there?

Dr. Cohen: We do ask that women either learn how to change it themselves or they come back to our office and we will help them change it approximately every 6-8 weeks. There can be more vaginal discharge with the pessary in place than there would be otherwise. Typically, we'll also ask them to use a topical solution to help maintain a PH balance within the vaginal canal when they have the pessary in or perhaps an estrogen cream itself. But, usually, it's pretty low maintenance therapy.

Melanie: And so, when we're combining this with incontinence, which as I said in my intro, it's difficult for women to discuss but you see these commercials and such. What kind of interventions, Dr. Cohen, can you do to address these issues with women when they come to you?

Dr. Cohen: Sure. I think the most important thing to note is that this shouldn't be a topic in the dark. This is a quality of life issue and in today's day and age, you shouldn't have to limit yourself. We ask that you seek help. We want to help. That's why we're here. We have a great team at City of Hope that's very invested in making this as nice a process, as easy a process as possible. But, to go back to your question, the interventions are myriad. If it's everything from just plain old incontinence, we could do slings or hammocks to essentially restore outward resistance to the urethra. The urethra is a faucet. When the faucet's washer breaks, you have to replace the washer. Now, we can't exactly replace the washer but we can do a lot of things to reinforce the continence mechanism or the resistance of the urethra and improve that and then decrease the amount of leakage that occurs. If someone's having prolapse and incontinence at the same time, we can usually do procedures where we address both. It's all an issue of restoring anatomical support. We can do a vaginal surgery for prolapse where everything is done through the vaginal canal itself. We also can do robotic surgery now for prolapse which has been a well-documented operation with robotic assistance, sacrocolpopexy, provides a mesh augment placed through the abdomen, not through the vagina, to support the anterior, posterior vaginal wall and really elevate that whole vaginal canal towards the sacrum, and attach is to a ligament over the sacrum itself, a very strong ligament. Really, it's meant to fix the top of the vagina falling. We are noticing that a lot of people are using it now to fix multi-compartment prolapse. If you need to, you can always go back down below and do additional vaginal reconstruction for the prolapse at the same time.

Melanie: Are there certain things women can do, lifestyle modifications, that can help them? We hear about Kegel exercises and maintaining that good strong pelvic floor. What do you tell women about that?

Dr. Cohen: I tell women conservative therapy is always what I like to start with. If there is a woman who is willing to go through the rigors of pelvic floor physical therapy, and I say that because good pelvic floor physical therapy is not easy. It's not an easy process. You've got to go every week. You've got to use muscles you've never used before. It's a workout. You really also got to have access to someone who knows what they are doing. You got to have a good pelvic floor physical therapist working with you to make sure that you are getting the appropriate treatments. If you're willing to do that, if you're willing to go to the sessions, if you're willing to do the exercises at home, some women do find benefits, especially in the realm of incontinence. That can be very helpful. So, I would encourage women to seek that out as long as they're getting the right care and they're actually diligent about going to those sessions.

Melanie: Is there anything else they can do that would contribute? Weight loss or nutritionally or smoking. Do any of those things have to do with this?

Dr. Cohen: For sure. Overall health wellness is something that cannot be understated. Like everything else in your life, no tobacco, weight loss, eating healthy, these are all things that not only impact your bowel movements, your pelvic floor health and may impact your overall health, no doubt, weight loss will improve and lessen your incontinence and decrease the prolapse burden you are seeing. No doubt that smoking less will actually improve outcomes after surgery. We know that women that smoke, if they undergo sacrocolpopexy, they have a higher rate of mesh extrusion over time in the vaginal wall, which is something we do not want to happen. So, no doubt, living a healthy lifestyle cannot be understated as something that could possibly impact your pelvic floor health.

Melanie: So, wrap it up for us, Dr. Cohen. It's really great information and such an important topic for women to hear. So, wrap up from incontinence to prolapse and back again, the ABCs. of pelvic floor survivorship following cancer treatments.

Dr. Cohen: Sure. I think, number one: cancer is a process that devastates. If you make it through that, if we can help you, if we can beat the cancer back, that's City of Hope's primary goal and they do a fantastic job of it. But, the journey doesn't end there. Once you've finished that, if you're having issues with incontinence, with prolapse, with bladder dysfunction, with fecal incontinence, you should not have to live with these battle scars. We are out there to help you. We are out there to make your life better whether it's through conservative therapies, whether it's through surgical endeavors, there is a very, very good team here at City of Hope that would rival anywhere else in the country composed of myself, Dr. Jonathan Warner and Dr. Christopher Chang, as the pelvic reconstructive faculty. I think the three of us, with all of us here, amongst us, we could probably tackle anything. I truly believe that. And, so, we would encourage you to seek out help .We're here and we would love you to come here and let us give you our insight into whatever we can provide.

Melanie: Thank you so much for being with us today. You're listening to City of Hope Radio and for more information, you can go to www.cityofhope.org. That's www.cityofhope.org. This is Melanie Cole. Thanks so much for listening.