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Pelvic Organ Prolapse

Emily Weber LeBrun MD discusses Pelvic Organ Prolapse. She shares insight into some key recommendations for practice and how first line conservative management can offer women an improved quality of life.

She helps us to understand the frequency of pelvic floor disorders and recognize the typical symptoms experienced by female patients with pelvic organ prolapse. She identifies the critical elements of an evaluation for pelvic organ prolapse and provides guidance for patients regarding treatment options, and she describes the fundamental surgical procedures used to treat pelvic organ prolapse.
Pelvic Organ Prolapse
Featured Speaker:
Emily Weber LeBrun, MD
Dr. Weber LeBrun is an associate professor and chief of female pelvic medicine and reconstructive surgery in the UF Department of Obstetrics and Gynecology. A Gainesville native and University of Florida College of Medicine alumna, Dr. Weber completed her residency at Baystate Medical Center at Tufts Medical School. She then completed an accredited three-year fellowship in Female Pelvic Medicine and Reconstructive Surgery and earned a Master of Science in Clinical Investigation at the University of Massachusetts in Worcester. She is uniquely skilled in the treatment of women with pelvic floor disorders and as part of the UF Pelvic Floor Program; she collaborates with UF physicians in other departments to provide multi-disciplinary care to patients throughout North Central Florida.
Transcription:

The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole (Host):  Pelvic organ prolapse is an extremely common female health condition. Today, we’ll understand the frequency of pelvic floor disorders, and recognize the typical symptoms experienced by female patients with pelvic organ prolapse. We’ll identify the critical elements of an evaluation for pelvic organ prolapse and provide guidance for patients regarding treatment options. Joining me today is Dr. Emily Weber LeBrun. She’s an associate professor and chief of female pelvic medicine and reconstructive surgery in the department of obstetrics and gynecology at the University of Florida and UF Health Shands Hospital. Dr. Weber LeBrun, it’s such a pleasure to have you join us today. Tell us a little bit about pelvic organ prolapse. Please help us to understand the frequency and incidence of pelvic floor disorders.

Emily Weber LeBrun, MD (Guest):  Sure. Thank you so much for having me. Pelvic floor disorders are ubiquitous throughout the community. At least 50% of adult women will experience symptoms such as urinary incontinence and other pelvic floor disorders such as pelvic organ prolapse. Prolapse in particular, is the phenomenon in which women experience a descent or bulge symptom of organs falling through the vaginal canal and becoming physically visible or palpable on the outside of their vaginal opening. These organs can include the bladder, the rectum, or the uterus and in a setting where a woman does not have a uterus, say she’s had a previous hysterectomy; then the top of the vagina or the vaginal vault can descend to the opening of the introitus.

Approximately one in five women in the United States will undergo surgery for pelvic organ prolapse or urinary incontinence and approximately 20 to 30% of those women will have a repeat surgery. Therefore it’s an extremely common problem and with the growing baby boomer population becoming of age in this target incidence around 40, 50, 60 years of age; there’s lots and lots of people suffering with these sorts of problems.

Host:  Well it certainly is very common. So, let’s talk about the clinical presentation and how providers can recognize those typical symptoms experienced by female patients. Tell us a little bit about that.

Dr. Weber LeBrun:  Sure. While some women remain mostly asymptomatic; other women present with very distressing symptoms such as something feeling like it’s coming down or falling out of the vagina, a feeling of a vaginal bulge is probably the most specific symptom related to this. Some women feel uncomfortable when sitting for a long time because they feel like they are sitting on a water balloon. Others feel more comfortable laying down. Prolonged working, standing up, lifting, those sorts of activities are particularly bothersome to women who have pelvic organ prolapse. And what’s helpful for providers to understand is that the presence of prolapse itself is not particularly risky or dangerous. But it’s the symptoms that it produces that merit referral or management.

Host:  Dr. Weber LeBrun, do you feel for other providers, that they should be asking women about symptoms of pelvic organ prolapse because otherwise, these women might not mention some of these, they might be embarrassed or think it’s a normal part of aging or what they are feeling is just from having babies or whatever the reason is. Do you feel that this should be part of an annual screening, something that they are discussing with their patients?

Dr. Weber LeBrun:  I do think that providers should engage women a little bit more than we are about issues related to their pelvic health. Pelvic organ prolapse happens to be one of those problems that does not necessarily require a referral but giving a woman some information about the symptoms that they are feeling and putting some perspective into it can be helpful. So, many women who might have pelvic organ prolapse at least visible on a physician’s exam; they may not have any symptoms and so if they have no symptoms, they need not be alarmed, they need not take any action and referral is not merited. But it can be helpful if you – if a provider sees it on exam to just let a woman know, heh by the way, your bladder looks like it’s a little bit down. There’s no problem, 75% of women presenting for an annual exam who are asymptomatic may rule in as having stage one prolapse which does not need intervention but just a little sort of friendly public service announcement if you will about it.

What is not so helpful, is if providers see pelvic organ prolapse on their exam and then kind of raise a red flag to the patients and say oh you definitely need this taken care of. Because again, if they don’t have any symptoms, it likely is not producing any health sequelae and does not need to be referred.

Host:  Well that’s so interesting. And thank you for that so, as we’re talking about treatment options and discussing those treatment options with the patient; considering quality of life assessment in determining appropriate treatment; tell us some key recommendations for practice. What do you want other providers to know about the treatment options that are out there?

Dr. Weber LeBrun:  Sure. There’s really only one or two circumstances in which prolapse can cause a negative health sequelae. The first is if the prolapse is so large, that a woman is unable to completely empty her bladder. That can make a person more inclined to have bladder infections, also called urinary tract infections or hydronephrosis, back up of urine into the kidneys. The other situation would be if it’s causing rubbing or bleeding from being dry and exposed. And basically all other circumstances, the four reasonable discussion points to have with a patient include the safety of observation and continued monitoring without any action, the use of a pelvic pessary, a vaginal pessary which is a silicon device that fits up inside the vagina and holds up the pelvic organs to provide support, much like a diaphragm in terms of size and shape but has a mechanical effect. The third would be the use of pelvic floor physical therapy which strengthens the muscles of the vaginal canal and the pelvis to help support those organs and therefore make the prolapse less symptomatic.

It won’t eliminate the architectural problem associated with prolapse, but it can delay surgical intervention. And then the fourth option would be to have a surgical treatment. There are many different ways to operate and repair pelvic organ prolapse. Some of them involve using mesh, some of them involve using the patient’s own tissue and it requires a very thorough and lengthy informed discussion with a patient about the most appropriate methods of treatment. I would say that by and large, patients who have mild to moderate prolapse would merit if they desired surgery, a native tissue repair that does not involve mesh. Those patients who have failed a prior repair or have an extremely large stage 3 or 4 prolapse might consider using mesh augmentation to make their repair stronger and therefore more durable.

Host:  Well so then when you’re discussing those kinds of treatments for stage 3 or 4 prolapse; women hear mesh, even other providers and they’ve seen things in the media; what do you want them to know about the mesh slings that you are using today and the safety and efficacy of them?

Dr. Weber LeBrun:  Understanding the nomenclature surrounding technical devices and implanted devices is critical. The word sling is frequently used to mean any piece of mesh put in the vagina, but it is not. It is simply and exclusively for the treatment of urinary incontinence. And so a sling is not a treatment for pelvic organ prolapse. There are other pieces of mesh that may have the same fabric, the same overall design but a different shape and different size and those are used for prolapse repairs for strength. But again, a sling is just for incontinence.

Historically, we’ve used mesh in two basic ways for treating pelvic organ prolapse. One is through a transvaginal incision in which we place a sheet of mesh into the space between two organs to provide extra support. For a whole variety of reasons, and with a whole variety of discussion points that we could have; the FDA has removed many of those products from the market. So, all of the transvaginal mesh kits that really got the lion’s share of the litigation and attention over the past ten years; are no longer available.

The second method of using mesh for pelvic organ prolapse is through a transabdominal laparoscopic or robotic, any one of those methods, approaches, in which the mesh is attached in the same locations but then supported up to the sacrum which is the area of bone just below the belly button essentially in the backbone. And that procedure is called a sacrocolpopexy. Sacro is sacrum and colpo is vagina. And so, it’s basically a pair of suspenders that holds up the vagina and uses mesh to do so. That mesh has not been criticized by the FDA nor has sling mesh been criticized by the FDA. So, there still are some excellent products out there to provide care for women who suffer from these pelvic floor disorders.

Certainly if a patient comes to my office and has significant concern about using mesh for their repair; then we discuss the actual data around those concerns and then provide her options. There are certainly almost always options that include not using mesh. It is at the cost of durability but certainly can provide patients more peace of mind if they want to avoid those mesh products.

Host:  Well thank you for that very comprehensive answer. As we wrap up Dr. Weber LeBrun, what would you like other providers to know about that assessment and evaluation for pelvic organ prolapse and when you feel it’s important, they refer to the specialists at UF Health Shands Hospital?

Dr. Weber LeBrun:  Certainly. For general OB-GYNs, really the lion’s share of primary prolapse patients, those who have a uterus and those who have never had surgery before can probably be managed in the generalist’s office either with observation, physical therapy, pessary or their first pelvic organ prolapse surgery. It’s important that providers who are doing those surgeries understand how to perform vaginal suspensions and if they don’t feel comfortable doing a comprehensive pelvic organ prolapse repair; that would be a great time to refer to a subspecialist. The second circumstance that would prompt referral would be if a patient had failed a previous surgery or had any complications associated with mesh. I do think that providers, general OB-GYNs in particular, do a great job of educating their patients about their pelvic health and it’s important to include pelvic organ prolapse in that in such a way that is not alarming to the patient and is reassuring that they can receive care when they feel like it’s necessary and impacting their day to day life.

Host:  Well thank you so much for joining us and sharing your expertise for other providers. Thank you again. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I’m Melanie Cole.