In an aging population, the prevalence of pelvic organ prolapse will continue to increase, requiring PCPs to regularly assess severity and recognize when intervention is warranted. Urogynecologist Caitlyn E. Painter, DO, explains why the anxiety-provoking condition requires sensitivity from providers and how they can help patients understand the problem and find a solution – from Kegels to surgery – that suits them. She also describes the benefits and limitations of surgery and lists resources to offer patient
um so you know just a little bit about me, I do full scope euro gynecology here at UCSF. Um including taking care of all types of pelvic floor disorders including pelvic organ prolapse, urinary incontinence and issues with mesh. Um So the goal for today, hopefully my slides will advance. There we go. Is to just review some basics about pelvic organ prolapse and how this may be helpful to you as primary care physicians and what you might see as as first line providers in the in the field. Um and when to potentially refer patients if you need more help and what you potentially could do yourself in clinic. All right. And so as we go through prolapse, were you talking about what it is and talking about definitions, what definitions are important for you to understand and what definitions are, you know more uh important for research and and where the field the female public medicine is going and then why should we really care? What you know, how does public organ or prolapse in general impact the health care system and impact women. We'll talk a little bit about the path of physiology and then um review some of the treatments and at the very end I have a few slides that are really good resources for you but also excellent resources for your patients. Where you can send them to these websites where there's downloadable leaflets that are you know publicly available and you know encouraged to be shared so that you can use that for yourself as well as for your patients. You know and I love this picture here on the side. Um this is from 1559. Um and it's just you know, showing you that prolapse is nothing new. It's been going on since women have been giving birth. Um and and so you know, this is something that uh many women have suffered from and uh that we've been trying to fix for a long time. So what is prolapse? So part of the tricky part about prolapse is is trying to get a definition. And the international continent society came together to create a glossary of definitions to really standardized terms, both to help with how we clinically speak about patients, but also to help with research and and and making sure that we're having um adequate and clear definitions. So we can document both the severity of prolapse as well as how effective our treatments are. And so their definition is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus and cervix or the apex of the vagina. That is the vaginal walls or cuffs car after hysterectomy. And what's important here is that the presence of any such science science should be correlated with relevant symptoms. Um and most commonly this correlation occurs about the level of the Hyman. So here is here is a picture down here of pretty severe prolapse and this is you know, showing what we would call presidential meaning the uterus and and kind of yet turning completely out or reverting completely out. So this is, you know, a severe form of prolapse here. So you know, a picture is worth 1000 words here for for prolapse. So I just wanted to show you know, some, some ways that you may see prolapse in your clinic if you decide to do a pelvic exam. So here on a that this is really um a pickle or or um cervical prolapse. So you see the cervix right at the opening of the vagina and this is definitely where people would be symptomatic as they feel it right at the opening. Be here. That in the middle is what we would call post hysterectomy vault prolapse. And what these two clamps are holding out here is the vaginal cuff guard. You can see when you pull it, it basically completely everts out here. And then see on the side here is a picture of prolapse where you see both the cervix coming down. But you also see the anterior vaginal wall coming. And then what's most notable here for me is that this is the genital hiatus or the rope opening of the vagina. And that's that's also pretty dilated and open here and and a sign of sometimes more severe prolapse. So different things that we look at when we're evaluating prolapse. And so a picture is worth 1000 words. This is what we're going to be talking about today. So one of the key important parts about prolapse is that it's never a secret and that was goes back to the the I. C. S. Definition. But it needs to be symptomatic. So there's really not a symptomatic prolapse. We've moved away from that and that's been demonstrated in several different studies. Looking at the prevalence of prolapse and we have a difficulty defining the prevalence of Prell Because if you define it based off of what you see on exam, 97% of women that have had babies are going to have some type of prolapse. Now, not all 97% of these women are symptomatic. Um and so we have to be be careful about how we define it. And really we've moved from looking at exam only to looking at What are the women's symptoms and how can are these symptoms related to the prolapse and how can we address that. And so when we look more at symptoms, women coming in describing a bulge a pressure protrusion of tissue. The prevalence really comes down almost to about 10% or less. Um and so most women start to become symptomatic when the prolapse is close to the high middle ring. So you know about a centimeter above to about a centimeter below. That's when they start to become symptomatic and that's because that's where our sensation changes. So above the level of the hymen that's where we're more sensing um through our autonomic nervous system and then at the human level and below. That's when we change to a somatic innovation. And so we start to feel and experience sensations differently at that level. So if you have, you know, if you're doing a pelvic exam and you see a little bit of pelvic relaxation, but the patient isn't really complaining of it, you don't have to worry them, you don't have to say, oh, you have some prolapse here. Maybe this is what's going on. It's really when they're having symptoms that we need to be addressing this as an issue. And the classic symptom, one of the best things that you can ask for perhaps is the sensation of a bulge. So, do you feel a pelvic bulge? Oftentimes, you know, when I'm asking my sort of, Euro kind review of systems, I say, if you have a sensation of a bulge within the vagina and people that have prolapse will say, yeah. And then people that don't have prolapse will say, well, look at me and they're like, what I don't even know what you're talking about. And I tell them if you don't know what I'm talking about, you don't feel that, then you don't have it. Um And and that's uh pretty sensitive and specific. The pressure gets a little bit more interesting. Um and it is not always the best way to describe it because there's lots of things that can cause public pressure. Constipation can cause public pressure. You don't, fibroids can cause pressure. The protrusion of tissue is pretty classic. So they'll say, I see something coming out and and then this goes back to the urinary and bowel dysfunction. They need to push on this tissue to get uh to be able to pee all of the way, or I need to push on the around this area to be able to have a bowel movement. Um the other classic thing that patients will say is that comes and goes, it's worse at the end of the day, it's worth after I've done walk. If I lay down flat for a little bit, it'll go back in some days are worse than others. Um and and that is very, very classic of collapse as well. The sexual dysfunction is very um is not very typically pain. And this will get into a little bit of a quality of life of how pelvic organ prolapse affects quality of life of women. But the sexual dysfunction is more of an embarrassment. They feel uncomfortable. They they have body image issues. They um you know, they it's more of uh you know, a mental thing. I'm so scared that this thing is coming down. I don't know what it is. I I don't want anyone to touch them there unless the sexual dysfunction in the way of like, oh, sex is is painful and that's why I'm not doing it. It can be a little bit uncomfortable, but it's not typically described as pain. Um, and so then that goes to my next point is that pelvic organ collapse typically doesn't hurt. So it is uncomfortable. It's annoying, it's pressure, but it's not painful. So if if women are coming in and their main complaint is pain, I have pelvic pain, it's typically not the prolapse. Now, certainly, pelvic organ prolapse and pain can coincide. We definitely see a lot of that. And there was this wonderful study done in a year old guide clinic where they actually assessed pelvic pain and prolapse and they came together pretty frequently. Um, But what they also found was that a lot of the symptoms of pain came from pelvic floor muscle pain. Um, and I see that frequently in my clinic. Now, the severity of the pelvic floor muscle pain was not correlated with objective symptoms of prolapse. So that is like the seeing or the feeling of the bulge or needing to push on the bulge to start urination, but it was correlated with this pressure or this heaviness in the, in the vaginal area. So, so the point of this is to say that, you know, there's a lot of things that can be going on in the pelvis that can cause pain and pressure that may not necessarily be just the prolapse and this is important to differentiate. Um, in the beginning, because, you know, sometimes people think like, oh, if you surgically fix my prolapse, then, you know, all of my pain is going to go away. And and that's certainly not true. And so you know, being very clear from the beginning about that, what what prolapse is causing symptoms and and and the symptoms that are associated with the prolapse versus something else like the pelvic floor muscles. There are many, many, many validated questionnaires now in the field of your gynecology that look at, how do we assess symptoms of pelvic floor disorders? And specifically looking at public organ pullout site. I've copied one here because it's you know, it's it's simple and it's a few, a few questions that you can ask and it can let you know oh am I on the right track with pelvic organ prolapse? Or or is this something else? Um and sort of how symptomatic is the prolapse for them? And so number three is the one that i is the one that I say, do you have a bulge or something falling out in the area of your vagina. Um and that usually helps me get to the prolapse right away. So just this I think is less important um for how you talk about prolapse um versus a you're a gynecologist, but I do think it's worthwhile to just think about the terms because of the way it impacts the patients. So there's lots of terms that go with with female public organ prolapse. Um and I've just listed a few. So sis to steal rap to seal and terrace feel. Those are some of the classic older terms that were used and they're still used and they're still part of I. C. D. 10 codes and they kind of get thrown around. Um But but the I. The the I. C. S. Has done a really good job of creating specific terminology for where the prolapse is occurring and they have them side by side here. And the reason why this is important because of the way patients perceive this. So they come in and they say oh my bladder is falling out. I was told I have a sister seal and they think that the problem is their bladder when actually the problem is not their bladder. So you can hear see here kind of on the bottom right hand side. This is a picture looking from the side view in of the bladder prolapse ng down. So this would be your classic sister seal. Um And the term we use now is anterior compartment prolapse I think and you know in general you don't have to worry about compartments. You can just say oh you have prolapse. Um and and the reason why this is important because it's super freaked out that they think their bladder is falling out, oh my bladder is falling out. So what I'm feeling is in my bladder, I'm touching my bladder. Same thing for the rectum. You know the top picture here is a compartment prolapse or what was used to be referred to as a rectal sailor and terrorist seal the patient starts to think there's something wrong with my rectum. Oh my rectum is coming out, My rectum is is falling out. And so I get a lot of patients that come in and they have uh pelvic organ prolapse, that is a post your compartment prolapse. But they think it's rectal prolapse. Um and rectal prolapse is a whole another talk that we could talk about that another time, but this is not not rectal prolapse and it gives them extra anxiety and and fear. And then when I explain to them, you know this is not the fault of the uterus, this is not your bladder, this is not your rectum, this is your your vagina and the support structures that are holding up the vagina, that's coming down. What you're actually feeling is a holding out during the version of the vaginal epithelium. So what you actually feel is vaginal skin and for for whatever reason that calm them down a lot rather than them coming in and be like oh my gosh, my bladder is hanging out between my legs. Um some of the words that I use for patients is I say, oh you know the top of your vagina or let's say the feeling of your vagina is folding out and that's what you feel. And then on the other side what lives above there, but inside your body is your is your bladder and so on the other side of this wall is your but it's not it's not necessarily that your bladder is falling out into your hand and that kind of helps them a little bit. So I I sort of instead of saying the post your compartment and the anterior compartment I talk about it as the ceiling or the floor and that helps the patients to to understand this. Um And that's really why I think the terminology is important um is mostly to convey to the patients and let them have an understanding of what's going on with prolapse. Um I put this here just because I think we talked about a lot. You see it a lot. It's actually included in some of the I. C. D. Codes now. Um The but the staging and the grading of prolapse has changed over time. I really like this kind of view on the side here because it shows for different iterations of how we staged and graded uh Prolapse. And for the most part right now since 1996 we've been using what's called the pa. Q. Which is on the side here and which is this picture with all of these numbers and figures. And and I don't think that you need to to remember this. I don't think you need to remember the stages nor how to actually do necessarily a pop Q. It's important for Euro gynecologists and people that are doing surgery for pelvic organ prolapse one so that we can, you know, communicate the severity of what's going on. We can really use this to help define anatomically where things are happening, but also so that we can follow outcomes. Um and its most important in in research, so we can be defining success and failure rates within the treatment of public organ prolapse within research so that we can improve the treatment of women with pelvic floor disorders. Um And I wanted to include just so you can kind of see um What we talked about like if if you know you send me a referral and I send it back and I say, oh she has stage three prolapse, what that means while we're talking about the pop que stages, which is here listed all the way on the right hand side of the screen. It's not a perfect system. It was developed in 1990, I don't think that we're going to change at any time soon, but it's not a perfect system. It doesn't capture everything for a pelvic organ prolapse, but it is good enough for now. Um And you know, I think what's most important is this stage two here because this is really number one, it's where most women are. So most women are going to be around the stage to if they have a kid. Um It's also where most women become symptomatic and and and that's because it's right at the level of the in Detroit us. So here if we look at the picture on the left hand side of the screen, if this is the android is here, if the distal most portion of the vaginal epithelium comes to one centimeter outside of the hymen when they bear down, that's that's the stage two. If it doesn't quite come to the hymen and it's like one centimeter above the hymen. That's a stage two. And right in that area is where they start to become symptomatic. Stage three and stage four and more advanced prolapse. Stage four is when it is completely all the way out. It's like a sock turned completely inside out and that's where we start to use the term presidential. Um and and stage three is that comes out of the Vagina. So it's actually coming out but it's not going completely to the whole length of the Vagina. So Stage two is our important one. I think it's helpful to kind of know that. Um So you can understand uh you know the staging that the patients are getting from us. Um and uh and and so that you can you know follow along as as the patients move forward with treatment. But I don't think it's necessary for everyone to be able to do a pop cube in general if you want to evaluate for whether you think they have prolapse or not. The easiest way to do this is to have them sit in lithography position. Use a half of a speculum or no speculum at all and just separate the labia and have them bear down if they can't bear down very well for you, you know, I would have them cough. Um And then you can see kind of how how much the vagina is coming down. I know that it's probably it probably varies within primary care practice. How many people are doing more women's health and doing more public exams versus versus not? Um I think it's important for all the doctors because another situation where I see perhaps maybe more urgent prolapsed concerns as in elderly patients where they have a more advanced stage three or stage four prolapse and it's coming down so much so tense that it's leading to some urinary retention. And I have seen acute on chronic kidney disease, basically an acute kidney injury from instruction from a prolapse where we reduced the prolapse they are able to avoid or we put a fully catheter in to empty the bladder and their acute kidney injury improves quickly after that. So even E. R. Physicians or uh or internal medicine doctors that aren't really doing much in the way of pelvic exams or women's health care, it's important for them to kind of to know about, you know what processing looks like. Alright, so why else does prolapse matter? So I told you that it's challenging to understand specifically the prevalence of prolapse because it depends on the definition, But if we use the prevalence of based off of symptoms, we we think it's somewhere around 6 to 10% of women. That being said, we know that our population is aging. And so this was a wonderful study done, um, uh, out of University of north Carolina in 2011. And basically, what they did was they looked at the population age estimates. So they looked at what we expect for population growth and what we know about population growth is that the women that are, excuse me, the the age group that's going to grow The most in the next 20 years is the age group that has the highest risk of prolapse. And so that's 65-75 year old age range. And so we expect that the age group that's going to have more prolapse is also the age group that's going to grow significantly in the next 20 or 30 years. And so what they did is they looked at, they said, well, if prolapse surgery rates stay about the same as what they are now, what is going to happen in in the next 40 years and they did this this modeling and you can kind of see it here on this graph, you know, this representation that it almost literally literally excuse me, linearly goes up over the The next 10 to 20 years where it's going to increase from 166,000 surgeries a year in 2010 to 245,000 plus in 2000 and 2050. Um, and so they're estimating, you know, a greater than 40% increase in the annual number of surgeries for prolapse. So if you look at some of the older data that was done in 2001, looking at, you know, what is the cost of prolapse surgery in the United States? If in 2001, it was one billion. We're also expecting that cost to go up. And so just like everything in healthcare, we're expecting it to increase costs, increased burden on our health care system as our population is aging and growing. And um something that is we should be cognizant of as this population is growing. And then the other reason to really think about, you know, prolapse is, is how much it is it impacts women. So it has been associated with decreased body image, um, and a negative impact on women's personal social and sexual life. And there, uh there's, you know, little studies that actually look at this very well. But if you talk to any Euro gynecologist, um there's all this anecdotal evidence of patients coming in crying saying, you know, I am suffering from this, my life is impacted. I can't talk to anyone about this. I'm embarrassed. Um, and the thing about pelvic organ prolapse is it's usually not on its own public floor disorders, including fecal incontinence and urinary incontinence go together. Um And they're often found um you know, it's pelvic organ prolapse is rarely pelvic organ prolapse without a little bit of urinary incontinence in there. And so some of these studies are looking at all pelvic floor disorder. So so it also includes the impact of urinary incontinence. But you know, specifically looking, there was one study specifically looking at women with just public organ prolapse and looking at depression scores and one sort of postmenopausal women did meet ph 29 scores for for depression. So it does lead to depression. Urinary incontinence certainly leads to social isolation. And then there was a qualitative study that was done um in 2015 that tried to assess women to see you know, what are actually the emotions that they're feeling when they're presenting for prolapse. Since all of these, your gynecologists are saying like, oh that's negatively negatively impact quality of life, is there any way that we can define it? And they, with qualitative studies, they, you know, they look at themes and they found three themes, so and they found emotions associated with the condition of products, so the condition itself. So so some women felt annoyed. Some women felt irritated, they felt frustrated, They were angry, they were sad, it caused anxiety depression. Um And some women just you know, just didn't have any feelings about it at all and tried to tried to completely ignore it. Um then there was the emotional burning and trying to communicate this. Um So not feeling comfortable to talk about this with friends, certainly. Um There's a lot of patients that do not want to talk about it with their family um especially in the aging population and then, you know, being embarrassed to actually talk about this with a health care provider, you know, saying, you know, I feel something falling out between my legs, um what do I do? And you know, just kind of being embarrassed about that when you get to after 65, a lot of these women aren't having pelvic exams anymore and so, you know, they don't want a pelvic exam anymore and they kind of feel embarrassed and afraid about it. And then the third treatment, the third theme that they found was that they also had emotions related to treatment, so that was both positive and negative. So there was anxiety, fear about treatment, but also like, oh, I could actually treat this and feel better. So so the the emotions related to treatment, we on both sides. Um and so as far as the emotions related to to to prolapse, it's not just the emotional burden of the prolapse itself, but also the emotional burden of trying to figure out how to communicate this to the people that may or may not be helping them. Um there's some older studies that look at, you know, is the prevalence of prolapse. Is it actually higher urinary continence is actually higher than what's reported in literature because women aren't presenting. And there's some there's some thought that the urinary incontinence and most certainly fecal incontinence is higher in the community than actually reported in the literature because women that just are embarrassed to talk about it. Um And so not only is phallic organ prolapse of public health concern with the burden and costs on our health care system, but it is also a concern for our patients and how it is impacting their their quality of life. That being said it's typically not an emergency. It's typically not a surgical emergency. And often times especially if they have a stage to prolapse that you know may bother them a little bit, but overall is not super symptomatic. Um And they just want some reassurance and they know that it's not dangerous, it's not their bladder falling out into their hand. Uh you can even just observe these patients. Um And as I alluded to earlier, there is one situation in which it is an emergency and that's when they have a complete presidential or a big tense prolapse that's causing specific urinary obstruction. The easiest thing to do is to put a fully in if you do have a pestering which we'll talk about later to hold the pull out back and that is something certainly that you know, they don't need to come to san Francisco to be seen for. Um But I I do know that it's not all clinics have have accessories. Okay, so so moving on a little bit too, why does it happen? Talking about the risk factors? Certainly a common question I get from my patients, why did this happen to me? Um It's really a multifactor loss of support. Um And so on the on the left hand side here, I have a picture of the support structures of the vagina and of the pelvis and uh you know, I don't certainly don't expect people to remember level 12 and three support. But basically the elevator a nine muscles in the pelvic floor and the surrounding and a public fashion all form a web of mechanical support for the bladder, the vagina uterus and rectum and they're all all sort of held out in multiple different levels. And so any damage to any of these structures will lead to a change in the elevator plate that change in the pelvic floor muscles that will increase the opening or the genital hiatus or sometimes called the elevator hiatus. And with that opening it creates a space for herniation of the public floor organs. So in other words, this is a vaginal hernia, there's a space just like the anterior abdominal wall if you have a defect in the musculature of the anterior abdominal wall, You can have herniation of the underlying organs. This is a defect in the maya factional structures of the public floor that's creating space that's allowing for herniation of the pelvic organs downward. And we are certainly not helped by gravity. I love this picture and analogy of the ship on the side here. So because the elevators are often are often looking like this little V. Shape here of the ship. And so the elevator muscles are on the side, these sort of ropes here. Uh and it's kind of holding everything up, holding above water. And then you get damage to these support structures here and the water goes down and the ship sinks and then and everything kind of goes down and then you get stressed on these elevator muscles and pull everything down. So if you if you think about the water, well then what's the water? What's removing the water here? And putting a strain on the elevator muscles? Well this is where we talk about the multifactorial. So so this is the other risk factors that's allowing for the water to decrease, decrease, increase. And the number one thing is childbirth. So the and and its specific things about childbirth. So it's just being pregnant in general increases your risk. So a cesarean section is not necessarily fully protective but in childbirth, it has a few other things related to it. So it's the parody. So so how many Children. Um And and we know that a grand multiple. So you know, greater than five deliveries. That does increase your risk. But but it's not like it goes up. So it's not like you're first baby, then your second baby is more than your third baby is more than your fourth baby is more. So not a linear increase in risk based off of the number of kids. They've actually shown that if you have one vaginal delivery and you have a second vaginal delivery, just adding one extra delivery does not actually increase your odds of having having prolapse. Um But it is it is at some point, increased parity does increase the risk of prolapse. We typically think about it greater than five Children. Vaginal delivery in general. But operative delivery specifically has been shown in multiple studies looking at um pretty significantly increased odds. So operative delivery includes vacuum assisted delivery, as well as forceps, forceps has, you know, fallen out of favor. But are certainly done. There's certainly still done here at UCSF that increases the risk greater than four fold of having prolapse in in the future. Um And and then birth weight, so greater than 4000 g is associated with an increased risk of prolapse in the future. The other is genetics. So that does play a significant role. And, you know, we as the future of precision, precision based medicine here at UCSF. We don't know the gene. So we can't say, oh we can do genetic profiling for you. We can see if you have this gene and whether or not you're at increased risk. But the reason why we know that it genetics is that it does run in families. So if your mother has prolapsed, if you're then you have an increased risk if your mother and your sister have prolapse, that doubles your risk. If you have three first degree relatives that have prolapse, that triples your risk. So with each relative that you have, um it does increase your risk more. So we do know that there's some genetics. Um and then obesity. Obesity is a pandemic in this country. It's going to get worse. You probably deal with it more than I do, but in obesity increases the risk of prolapse. It also increases the risk of urinary and weight loss. Even even just a modern amount of weight loss can can significantly improve, not necessarily prolapse symptoms, but certainly um urinary incontinence symptoms. And it can also improve our treatments that we do um connective tissue disorder. So the classic one is either stand Los uh Danlos patients do have increased risk of prolapse. Um They also have a lot of pain. And so they can be at their public for disorders can be difficult to treat. Um They they have an increased risk of surgical failure as well. Menopausal status is on there. Um And it's not clear if it's truly the menopause versus age, it seems to be more related to age. So an age related decline in, you know neuro muscular function more likely than menopause specifically related to estrogen. They did look at prolapse with within the women's Health initiative study and look at whether or not estrogen and progesterone supplementation change and actually adding estrogen does not uh does not decrease. Um The risk of prolapse. It also is not a treatment for prolapse. So it seems to be much more age related rather than truly menopausal related. Um and then anything where you're going to have constant pressure down. So chronic constipation is a big one, chronic cost COPD and increasing intra abdominal pressure. Um So one thing that we see at UCSF because we're a tertiary referral center for liver is patients with liver failure and societies can um have have pretty significant uh stage four prolapse with that, you know, the pressure of that. Besides, you know, if they've had a vaginal birth and they have space in their elevator muscles and that pressure is going to go down and herniated public organs through the public floor. Um So so these are, you know, it's it's not to say that, you know, everyone who's obese is gonna have it, but as you add these risk factors is multifactorial and these are the things that can lead to increased risk of pelvic organ prolapse. So what can we do about it. Um So like I said, you could do nothing. Um I definitely have patients that come in and have anxiety and they say my bladder falling out and I'm super freaked out and I do their exam and they have, you know, a stage one to stage two prolapse where the inter vaginal wall is coming down, but it's not coming down all the way to the Hainan and I do the exam and I explain it to them and we talk about prolapse and I explained to them this is not dangerous, it's not going to harm you. Um This this is what's going on, it's not actually that your bladder is falling out into your hands. And they say, okay, well now that you told me, it really doesn't bother me that much. And so I don't want to do anything about it. So, so we can certainly just observe um the the study of the natural history of Prolapse. So, trying to study these patients lodge eternally, has proven to be difficult. Um And so there's no great, you know, long term studies on this, but what we do know is that in about a third of patients, they sort of prolapse to a certain point and stay there. About a third of patients will actually get better with time. So without doing anything, some patients do actually just get better with time and then about a third of patients will continue to progress over time and there's no nothing that can say, you know where these patients are going to to be. Um And so for the patients that are not that symptomatic um that we're really just need some reassurance. We just talk about, you know, strategies to decrease their their risk. So I talk about, you know, avoiding constipation if at all possible, not straining every single day with bowel movements, making sure they're getting plenty of fiber um you know, maintaining an overall healthy weight and an active lifestyle. Um And then you know, avoiding things that may lead to a chronic cough. So avoiding cigarette smoking things like that. So you know in general it's really sort of common sense and and counseling about an overall healthy lifestyle. Um And usually when these people are seeing me, they're in their sixties uh sixties to seventies um That was my alarm for five minutes left to talk to you. So um what else do we have out there? We have public for muscle exercises. I love my pelvic floor physical therapist, they get a lot of referrals from me. So this is the classic kegels. Most women are not doing their kegels correctly, especially if they're coming to see me. So I too, we will send them to public for um physical therapy where they can do biofeedback. This is just an example of a biofeedback. So it's just a transducer probe that's put in the vagina connected to a machine. And so they can watch and see when they're squeezing and releasing. So they're actually coordinating the muscles correctly um And it does require a sustained effort. So uh in general how it's described as doing your kegels three times a day every single day. Um and you know, 10 sets, but um, you know, it's more, I think of kegel exercises more for stage one, stage two prolapse as well as preventative, you know, really, um rehabbing your public for muscles so that you don't end up with a stage for prolonged in the future. Uh second is a Petteri. So there are all sorts of shapes and sizes of pest series, all different kinds. There's no one size fits all. Um Pesticides have been used since the 15 hundreds. They used to use half of a pomegranate. They've used stones. They've used all sorts of things for pest series. Um currently we use silicone pastries. Um Most women can be fitted successfully for a pastry. Um Most women will be in the 65 millimeters range, which is, which is the number four pastry. If you're, if you're looking at the types of accessories. And so I do think that this is something that primary care physicians can fit for the challenges keeping these batteries in stock. If I were to just stop pestering just in my clinic, I would do this ring past three and this ring Petteri only and the ring would get some with incontinence knobs and I would mostly have number three and number four pastries. Anyone that's outside of that can probably go somewhere else. Um I have plenty of patients that are super happy with their pastries. And then last is when they come to referral for me for surgery. So I I listed all different types of surgeries here because I think it's helpful. I have lots of patients that are that come. They talk to me, they get a surgical consultation. They say I really want to go talk to my primary doctor about this. Um because you have the relationship with them, they want to talk to their primary care physician about. You know what they think makes sense. Do they think this is safe? Should they have surgery or not? Um And in general, when I think about Surgery and when I kind of explain it as a once over the patients, I say, you know, for patients that are older, frail that no longer want to use their vagina, I do recommend an obliterated procedure or a couple crisis, which is essentially closing up the Vagina Vagina. This is my favorite surgery to do because it's 99% effective. And as a complication rate of less than 1%, that's like an amazing surgical result. Um and honestly, for my women that are done having vaginal intercourse and our have severe prole out there, so happy with this procedure and they don't often need to take any pain medication afterwards, they're they're very satisfied. But that's not everyone, a lot of women that are coming to see me have prolapse and still want to have vaginal intercourse. And so then we're talking about reconstructive options in general. We can do surgery through the vagina. We can do surgery through the abdomen. We can do surgery with a hysterectomy. We can do surgery without a hysterectomy. We can do surgery with mesh and we can do surgery without mesh. Um And all of those different combinations. Kind of depends on the unique patient, what they're looking for. Um Their comorbidities. Why I might not want to be an abdomen. Why? They may not want mash things like that. Um I will say here that the just, you know, briefly this again could be whole other talk on its own. We do not put mesh through the vagina for prolapse anymore. These are these mesh kits that the FDA has recalled. I'm of a generation that you know, I didn't learn how to put those in. But I'm certainly of a generation where I've taken them out and they caused a lot of complications. Um And so the mesh specifically is reserved for the sacred corporal plexi which is here. So the mesh is placed trans abdominal lee and not through the vagina. And it doesn't cause all the same issues as the mesh kits. Um and so I wanna make sure I leave enough time for for questions. Um I will say that, you know, I talk to patients about conservative options before we jump right to to surgery. None of the surgeries are 100% effective. Um and especially if we're not using mesh, the surgeries tend to recur over over time. Uh That being said for women that are younger and really symptomatic and tried pestering, tried public floor exercises and it's not better. I say, you know, you don't necessarily have to live with this. So I don't make make people wait for surgery either if they're really symptomatic. Um All right. So as we conclude, I just wanted to put up two sides with the excellent resources for you. Um So both the international Euro gynecologic association or a yoga um have patient leaflets on there. And I put the website and a picture of the leaflets um where you can just print this out from your computer. You can just google it and print it out for them. It's free, it's free for them. It's free for you. Um The reason why I like a yoga is that they have different languages. Um So they, you know, depending on which condition you're looking at, they have different languages. The they almost all have spanish but they also have um some of the the different chinese languages as well. So that's why I like a yoga and then the next one is the american Euro Euro gynecologic society or org And they have a website called Voices for PFD dot org and that's listed here and I spend most of my patients to that website to look around. Not only are there these little pamphlets that you can just print out or you can copy the link and send it to them via my chart. Um but also that website has different videos, it has different patient stories, um and has sort of more of a community feel, and so I tell them, you know, I'm explaining this to you, but if you want to get this from other patients perspective, you can go to this website. So I like both of these websites. I think it's good uh for a primary care physician to kind of have in their, in their, in their pockets, so that they could, you know, easily give this information to patients, you know, while they're waiting potentially for a referral or something like that. Um and so with that I will close and I just wanted to put up my slide here that tells like how, how to get ahold of me, how to refer to me. Um but I think in order to be able to hear the question and answers, I may need to stop share, but let me just see if I can
