Vaginal Prolapse

Additional Info

• Audio File:uab/ua032.mp3
• Doctors:Richter, Holly
• Featured Speaker:Holly Richter, PhD, MD
• CME Series:Medical Innovations
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4217
• Guest Bio:Holly Richter, MD, PhD, J. Marion Sims Endowed Chair in Obstetrics and Gynecology.
  
  Learn more about Holly Richter, PhD, MD 
  
  Release Date: 10/3/2017
  Reissue Date: 10/5/2020
  Expiration Date: 10/5/2023
  
  Faculty:
  UAB MedCast: Urinary & Bowel Incontinence
  UAB MedCast: Vaginal Prolapse
  Holly E. Richter, PhD, MD
  Director, Division of Women's Pelvic Medicine and Reconstructive Surgery
  
  Dr. Richter has disclosed the following commercial interests:
  · Royalties - UpToDate
  · Grants/Research Support/Grants Pending - Allergan, Renovia
  · Other - DSMB Member: BlueWind Medical
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host): Nearly 40% of women will experience some form of pelvic organ prolapse. It most often occurs in women beyond the age of 40 and in relation to or following childbirth, menopause, or a hysterectomy. My guest today, is Dr. Holly Richter. She’s the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery at UAB Medicine. Welcome to the show, Dr. Richter. Explain a little bit about pelvic organ prolapse including vaginal prolapse, and what are some common conditions and factors that lead to this?
  
  Dr. Holly Richter (Guest): Sure. First of all, thank you, so much, for letting me come in today and talk about this very impactful condition that women can develop over time. Just to start off and provide perspective, approximately 10% of all women in the US may have surgery for pelvic organ prolapse and/or incontinence, and/or both of these conditions during the course of their lifetime. About 1 in 3 of those women may have a second surgery for these conditions. It’s really something that we really see a lot of in the post-reproductive health lifetime of a woman. Pelvic organ prolapse results from weakening of the support structures in the pelvis which lead to the woman feeling or seeing a vaginal bulge. One day she’ll be going to the bathroom and wiping, and she starts to feel something coming out of the vagina.
  
  There are numerous risk factors for this including having babies. It makes sense when a big head and shoulders come down through the small vaginal canal that it may injure supportive structures such as muscles or ligaments and other types of connective tissue. Increases in weight can lead to this. Medical conditions such as a chronic cough, high physical activity that really puts chronic stress on the pelvic floor, changes in hormones, all of these things may contribute to the development of this condition. In fact, as you know, this is a condition which is multifactorial. There also may be intrinsic genetic predispositions to the development of prolapse. In fact, genetic studies that are going on, most of them are going on in the area of prolapse at this time.
  
  Melanie: Do you have some valuable prognostic tools to aid in early diagnosis for a woman, or is there a history? What goes on with the diagnosis?
  
  Dr. Richter: In terms of diagnosis, I think many people that do a gynecologic physical exam may see that with Valsalva or with – when a woman presses down on the pelvic floor, they may see mobility of the anterior vaginal wall, or the apex of the vagina, or even posteriorly. Many women remain asymptomatic, and that’s okay. The problem typically comes to the level of needing help when the protrusion starts coming outside of the vagina or beyond the hymenal ring. That’s typically when a woman will come and start to seek some information regarding what’s going on here. Many women may think this is a cancer. Seeing something come down like this is very scary. This is where docs that do pelvic exams can really help allay a woman’s fear that this is not a cancer. It’s something that’s quite prevalent in women and that there is help for it.
  
  Melanie: Are there any complications if it’s left untreated?
  
  Dr. Richter: Really great question. If left untreated, any kind of tissue that’s protruding down and is somewhat in an abnormal position, the blood supply to that area can be impaired. When the bladder starts coming down, it kinks off the urethra so a woman may have symptoms of incomplete bladder emptying. The same thing when there’s weakening in the posterior vaginal wall. A woman may have symptoms of inability to complete bowel movements, or just feeling really a lot of heaviness and pressure after a day of walking around. I’m confining – I’ve only mentioned urinary incontinence, but along the same lines, these same types of symptoms of prolapse can also predispose to bowel incontinence and bowel issues as well.
  
  Melanie: What are some of the clinical challenges in the management of prolapse?
  
  Dr. Richter: Well, I would say that -- first off, in managing – if a woman is coming for treatment, you want to make sure that you understand all of the weaknesses that are occurring in the vagina. You want to optimize lower urinary tract genital tissue health, and estrogen is a very important part of this. I’m a big believer in the use of vaginal estrogen. It helps thicken the vaginal epithelium, the underlying connective tissue. It just makes things healthier down in that area for a woman seeking treatment. Treatment really comes from two main areas. There’s nonsurgical treatment with the use of devices called pessaries that can be placed in the vagina, and then there are surgical treatment options for women.
  
  Melanie: Is it a challenge for surgeons, Doctor, that you want the successful quality of life outcome for your patient --
  
  Dr. Richter: Sure.
  
  Melanie: but you also mentioned incontinence, so the associated symptoms of prolapse, and then do you have to deal with those as well while you’re dealing with the prolapse itself?
  
  Dr. Richter: Absolutely. When you’re dealing with prolapse, because the urethra can be kinked, the woman, if she has her prolapse fixed, may actually develop urinary leakage. That needs to be assessed before surgery for prolapse. Quite often, we’ll also take a look down in the posterior compartment area to ensure that if she – typically, in the posterior compartment area, if she presents with fecal incontinence type symptoms, we evaluate that more fully before surgery because if there’s something we can fix there – we’ll want to take care of all of these things in one surgery.
  
  Melanie: Are there some treatments and research that you’re doing at UAB that other physicians may not be aware of?
  
  Dr. Richter: Yeah, we’re actually one of currently seven sites in the NIH-sponsored pelvic floor disorders network. We do multisite research. A lot of that has been in the area of surgical treatment of pelvic organ prolapse. We are currently looking at a trial in women who have a pelvic organ prolapse after having had a hysterectomy. We’re looking at three surgical treatment approaches for the management of this type of prolapse and which one – and if one of them is better than one of the others, and if one may be associated with an increased risk of recurrence versus another. It’s really an exciting area of research going on right now.
  
  Melanie: And how do you make that decision with your patient on which type of surgery to have?
  
  Dr. Richter: That’s awesome. Awesome question. If I have a 90-year-old who has a total procidentia, she’s not sexually active, the pessary won’t stay in -- we’ll talk about doing an obliterative type of repair. Getting the prolapse up, but also really making things very tight down below, so it doesn’t come back out, but it essentially obliterates the vagina. That’s as opposed to doing a reconstructive surgery, say in a woman who’s still sexually active – these are some of the considerations that we make.
  
  Further, we can look at the type of approach to the surgery, whether we’re going to do everything vaginally – maybe she’s had a previous surgery before that’s failed and we may think about doing something from above with the use of mesh. Typically, in initial surgery, we’ll do what’s called a native tissue repair where we use the woman’s own tissue. All of these types of issues we discuss in an individualized fashion before doing a surgery for pelvic organ prolapse.
  
  Melanie: And what about a pessary? Are these something that – you mentioned for a certain age woman they won’t stay in, but is this a good option – a non-surgical intervention for a younger woman? Is it something that comes out or stays in?
  
  Dr. Richter: Yeah, great questions. Again, many younger women use a pessary. For the most part, they probably aren’t going to use it for the rest of their lives, but they may want to use it if they have some weakening of the pelvic floor and symptoms associated with this when they’re doing physical activity. They may want to have another child in the future so don’t want to take the uterus out at this time. For younger women, it’s typically a stop-gap measure.
  
  Then there are older women that just don’t want to have surgery. Maybe they’ve got medical comorbidities that keep them from going to the operating room, or they have no desire to have surgery. A pessary can be used chronically. It can be used for several years where we will fit a particular pessary for her needs, teach her how to put it in and take it out. Again, this is where vaginal estrogen is very important to maintain the health of the vagina.
  
  A pessary is a – and sometimes a woman just wants to try a pessary before moving on to surgery. I always offer every woman a nonsurgical treatment option. Now, she may not go for it. She may just want to get it fixed and move on, but it certainly is something that everybody should be offered.
  
  Melanie: In summary, Doctor, tell other physicians what you’d like them to know about recognizing prolapse in their patients and when they should refer to a specialist.
  
  Dr. Richter: Yeah, I think – well, prolapse is something that is managed by a specialist in female pelvic medicine and reconstructive surgery. Although, I would say that there are generalist Ob/Gyns that know how to place pessaries, and that’s a good thing because we need partners in the area of treating women with prolapse. But I think if a woman is really thinking about having surgery to treat the prolapse and cure the prolapse that she should be sent to a specialist for evaluation.
  
  Melanie: And how can a community physician refer a patient to UAB Medicine?
  
  Dr. Richter: Yeah, that’s a great question. We do have health finders. That is a service – I think that primarily patients are able to call and talk to a nurse specialist who can get them into the right doctors – to the right group. Doctors out in the community can call the UAB MIST Line at 934-MIST to contact any of the urogynecology docs here at UAB.
  
  Melanie: And a community physician can refer a patient to UAB Medicine using the MIST Line at 1-800-822-6478, that’s 1-800-822-6478. And tell us about your team, Dr. Richter, why is UAB so great to work with?
  
  Dr. Richter: We’re all board-specialized female pelvic medicine and reconstructive surgery specialist, and we’ve been doing this for twenty years, plus. In fact, one of my partners has been working in this area for thirty years. We’re training our future. We have an ACGME-Certified, three-year fellowship program. We not only take good clinical care of women, we’re trying to improve the care of women with prolapse through research initiatives as well as educational initiatives. This is all I do. This is all I – I don’t deliver babies; we don’t do pap smears. This is an area that’s very emotional for women, so you really want someone who takes the time to explain things, who has experience and expertise in all aspects and can offer a full spectrum of treatment options for women with this condition.
  
  Melanie: Thank you, so much, for being with us today. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks, so much for listening.
• Hosts:Melanie Cole, MS