Pelvic Organ Prolapse, Incontinence and Beyond: Expert Q&A
January 22, 2021
And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. And let's start off by having each one of you introduce yourselves. And tell us a little bit about what you do here at UChicago Medicine. And Dr. Valaitis I want to start with you.
Hi. My name is Dr. Sandy Valaitis. I am a Professor of OB-GYN and a fellowship-trained boarded urogynecologist boarded in female pelvic medicine and reconstructive surgery. I also serve as a section chief of urogynecology at the University of Chicago, where I've been recently since 2005. And I'm also Vice Chair for Faculty Affairs in our department.
Great. And Dr. Letko?
Hi, I am Juraj Letko. I'm a urogynecologist. I'm an Assistant Professor of Obstetrics and Gynecology at the University of Chicago. My background is I trained as a urologist in Europe. And then I did residency in obstetrics and gynecology in the United States, and subsequently, fellowship training and board certification in female pelvic medicine and reconstructive surgery.
OK, we're going to start off from kind of just in broad general terms. And then we'll kind of narrow down our questions as we go. And Doctor Letko, I'm going to start with you. And just, if you can tell us a little bit about urogynecology, and what that is, and what kind of patients you take care of?
Well, urogynecology is a subspecialty that-- it's called female pelvic medicine and reconstructive surgery. It's a subspecialty between urology and gynecology. We take care of pelvic floor disorders.
The bread and butter, the most common conditions that we take care of are pelvic organ prolapse and urinary incontinence, but we deal also with a lot of complex problems like urogenital fistulas, mesh complications, recurrent symptoms after pelvic organ prolapse surgeries or urinary incontinence surgeries. And we work in collaboration with other subspecialties and specialties that deal with these problems under an umbrella of Center of Pelvic Health at the University of Chicago. And these include urology, colorectal surgery, pelvic floor physical therapy, radiology, as well as plastic surgery.
And we do want to remind our viewers that we will take your questions live on the air. So just type them in the Comment section either on Facebook. And of course, we're broadcasting now live on YouTube as well. So you can type them in the comments section there as well. And we'll try to get to as many questions as possible over the next half hour.
Now, Dr. Valaitis, if you can tell us a little bit about-- Dr. Letko just mentioned a fistula, which is one of the more complex things that you deal with. Can you tell us what that is?
Oh gosh, a fistula is an abnormal communication between two organs. Most commonly what we deal with in urogynecology is what's called a vesico-vaginal fistula, which is a communication that forms between the bladder and the vagina. There is also something colorectal rectovaginal fistula, which is an abnormal communication between the rectum and the vagina. And there is also something called a ureterovaginal fistula, which is an abnormal communication between the ureter, which is the tube that drains the kidney into the bladder, and the vagina.
And then there is something called a urethrovaginal fistula, which is a communication between the urethra and the vagina. And these can be the result of a variety of things. Typically they might occur after some type of surgery like a hysterectomy, or after some type of infection like diverticulitis, or after childbirth one might develop some type of a fistula.
Typically a rectovaginal fistula can occur after a bad tear during a delivery. Radiation or cancer might be causes for these problems as well. Or sometimes inflammatory bowel disease like Crohn's disease or ulcerative colitis can result in these kinds of problems. And they can be quite difficult to manage. And they're extremely distressing for patients to have them.
You know, it's interesting. We had the opportunity-- we're very fortunate-- to talk to a patient, Lisa Welz. And she was very kind and wanted to share her story. And she-- we're going to have several sound bites that we'll play from her throughout the program. And she kind of talked about just the impact that this had on her. And, John, let's play the first sound bite when she talks a little bit about her background of her situation. And this is, I believe, before she came to UChicago Medicine.
Overnight, they ran the tests just to see if there was any fluid leakage. And I didn't realize that they were checking my bladder. And then so the next morning, that's when it was explained to me that there was a hole in my bladder, or what-- well, there was, but it was a vesico-vaginal fistula, which I had never heard of. And I was like, what is that?
And basically, it was explained that it's like a tunnel opens up between the bladder-- which, mine was at the back in the bottom of my bladder-- and at the very top of the near the top of the vaginal cuff. And so it's like two openings and a tunnel between them. So essentially what I thought was surgical fluid was urine, but it was just draining straight through.
So as a result of that, they gave me a catheter. And so you come out of surgery with a catheter. And I was told that-- I was told that it could heal itself. So I spent the next month praying that it would heal. And it didn't.
And you can see just how emotional of an experience that is for her. And I certainly, I can't imagine how difficult it would be to deal with that. And Dr. Letko, that's one of your patients. We will play the other sound bites for you, a happy ending to that story, here in a few minutes. But Dr. Letko, can you tell us a little bit about just how do fistulas actually occur? We kind of know what they are now, but how do they happen?
Well, the most common reason for development of fistula is actually, currently in developed world, surgery, and gynecologic surgery, specifically hysterectomy and abdominal hysterectomies. But it can occur due to other reasons like prolonged labor, for example, cesarean section, in cancer patients, for example, due to radiation and poor healing. And those are some [INAUDIBLE].
So how are they treated, then?
Well there are, I mean, several ways. There is conservative treatment. There is some evidence that very small fistulas can be treated conservatively. And they can close on their own with temporary drainage. However, the vast majority of fistulas actually have to be treated surgically. So it has to be resorted to surgery, unfortunately.
And surgical options that exist for fistulas are either vaginal approach or abdominal approach. So all of these surgeries are done in a minimally invasive fashion. So even when we have to do abdominal surgery, we do it laparoscopically through, or robotically, so through very small keyholes which enhances the recovery of the patients and also the success rate.
So Dr. Valaitis, you mentioned fistulas between the bowel and vagina. How are those treated? Is that a different procedure or a different type of treatment?
Yeah, it kind of depends on where the fistula is located. So often with childbirth, the fistula is related to a bad tear when the baby delivers or possibly an episiotomy that breaks down. And there is then the communication that forms very low down on the vaginal wall between the rectum and the vagina. And those are often treated surgically with just basically dissecting open that area and putting in some stitches to close both of the spaces and separate them so that they heal properly.
Sometimes very small fistulas might be treated with something called a seton, which is like a little device that's placed in the hole that stimulates an inflammatory response and healing of that area to close. If the fistulas are higher and they're related to perhaps diverticulitis, or radiation, or some other more complicated cause, often we do need to work together with our colorectal surgery colleagues through our Center for Pelvic Health, like Dr. Letko mentioned earlier. And we do a more complicated surgical procedure that often involves some bowel surgery as well as closing the hole in the vagina.
So what's the recovery like after a surgery like that?
Go ahead, yeah.
Oh, generally the patients go home either the same day of the surgery or the following day after surgery. And basically, they can return to fairly normal activity. Unfortunately, for a period of time of about 10 to 14 days-- I mean, it depends on what kind of fistula it is.
If we're dealing with urinary fistula into the vagina, usually they have to have a catheter for about one to two weeks, which is removed after it's confirmed that the fistula actually healed at this period of time. For rectal fistulas, generally there is just a specific special diet, low residual that is sufficient. And there is no drainage actually very often needed.
So let's hear a little bit more about Lisa's story. And we're going to play the second sound bite, John, where she talks about taking control of her destiny. And this is where she started doing some research. And eventually it led her here to UChicago Medicine.
And I'm thinking, for goodness sake, I've been a journalist for how long? Now I'm a copywriter, but I still have all of those research skills. Let's use them and find out who I need to go to. This time I'm making the decision.
My dad had been at University of Chicago hospitals many years ago in the early '90s with a glioblastoma brain cancer tumor. And while that's nothing that you want to have, and that in itself isn't a good experience, the people at the hospital and the doctors that we dealt with were amazing. And so I decided that I wanted to find someone connected with that hospital. And that was a Thursday that I called when I got home. So within 2 and 1/2 hours of my disappointment, I had an appointment for the following Tuesday.
That's pretty good. And we'll play the third sound bite here in a few moments, but it's the care that she received is, by your team, obviously, is quite good. Dr. Valaitis, can you tell us-- one of the things that, as we started the program, we talked a little bit about pelvic organ prolapse. And let's start, first of all, if you can, just tell us what that is.
So pelvic organ prolapse is a very common condition that affects women. And it creates basically a loss of support of the vaginal walls such that the pelvic organs, the bladder, the uterus, and the rectum can then start to pouch down, creating a bulge in the vaginal wall, which can sometimes start to protrude out through the vaginal opening, which can be very distressing. You're not supposed to have things bulging there if you're a woman.
So that often creates a lot of distress. It's not usually painful, but it can be uncomfortable. You sort of feel it there. It gets in the way. People become quite self-conscious. And there are many things that we can do to help with that problem.
Great. And Dr. Letko, how common is that? Well actually, pelvic organ prolapse is a quite common thing. About 50% of adult women actually have a certain degree of prolapse up to actually about 1 centimeter to the opening of the vagina.
So it is very common. And these women are-- most of them are asymptomatic or have very mild symptoms. Usually women start to be more symptomatic and seek care once the prolapse reaches the vaginal opening or protrudes outside.
So Dr. Valaitis, how does it actually develop though? I mean, you mentioned kind of what the precursors, but what actually happens to make that develop?
Well, the most common denominator of this condition is childbirth. So we know that vaginal delivery in particular can increase the risk of a woman developing this problem in her lifetime. However, there are women who have never had children or any pregnancies who can develop prolapse as well.
So there is other factors that probably play a role, including genetic predisposition to weak connective tissue. So there are some connective tissue disorders that can be inherited that might predispose somebody to developing prolapse. There is also things where patients actually participate in heavy lifting a lot. So they might have an occupation which requires them to do a lot of strenuous activity and heavy lifting.
We know from epidemiologic research that nurses who do direct patient care have a much higher rate of prolapse as compared to their colleague nurses who do more office-type work or administrative roles. So heavy lifting definitely plays a role. And then chronic cough might actually predispose someone to developing prolapse, chronic constipation, so basically any kind of condition that causes you to strain a lot and increase the intra-abdominal pressure inside your abdomen.
That pushes a lot of pressure down on the pelvic organs and can then predispose somebody to prolapse. It is a little bit more common as you get older. Probably some of the changes that occur with menopause and some loss of elasticity in the tissue with menopause might predispose somebody to getting it as well.
So Dr. Letko, I know the question that a lot of people have at that point is, is there anything that can be done to actually prevent that from happening? Well, there are risk factors, many risk factors for developing these conditions, as Dr. Valaitis mentioned. Some of them, unfortunately, we cannot do anything about, like, for example, age.
But the main prevention or the best prevention of these problems is basically maintaining a healthy lifestyle, so maintaining a healthy diet to prevent, for example, obesity, so decrease the pressure that is put on the pelvic floor. It also, the healthy diet, prevents constipation, for example, so chronic straining. Pelvic floor exercises can improve symptoms or maybe slow down the progress in patients with pelvic organ prolapse, but they can also benefit other conditions like overactive bladder, for example, or stress urinary incontinence. Also treatment-- Dr. Valaitis mentioned chronic cough. For example, treatment of chronic conditions like asthma, emphysema that cost increases pressure on the pelvic floor, that helps to prevent these problems.
So Dr. Valaitis, if you're at this point that you know you have this happening, what are some of the treatment options that are available
Right, so behavioral modification like Dr. Letko was alluding to, watching your diet, making sure you have constipations under control-- perhaps if you can modify some of your activities and not lift as many heavy things or get help lifting, that can be helpful. We refer to many of our patients to pelvic floor physical therapy. And we just have fantastic colleagues in the physical therapy department at our institution who help us take care of these patients. And they do a wonderful job at teaching women how to strengthen their pelvic floor, because doing so might help prevent the progression of the prolapse if it's not too severe.
There is sometimes some come and go of these symptoms. So at some times the symptoms might be better. And other times they might be worse. And so doing some conservative management of the problem might be very helpful for patients and may help them prevent the need for surgery.
But many times if the prolapse becomes quite severe and it starts to protrude outside the vagina, there is other treatment options that we can offer, which include a pessary, which is, like, a special insert. It's usually a round ring-shaped insert, a little platform in it almost like a diaphragm, that is placed into the vagina to support the pelvic walls and lift things back into place. Or there are surgical options for managing it. And the surgical approaches vary depending on what the needs are for the patient and what other risk factors they may have, especially.
So Dr. Keto, does the uterus have to be removed during prolapse surgery?
Not necessarily. Traditionally, I mean, the usual patient is in menopause or older of reproductive age. So generally, traditionally, these surgeries are performed with or have been performed with the removal of the uterus, but there is increasing evidence and research done that, actually, preservation of the uterus during the surgeries. Can result in comparable results so this is definitely an option.
So Dr. Valaitis, another area that I think is of concern is urinary incontinence. Can you talk us through that a little bit?
Sure. Well, how much time do you want me to spend?
We've only got about 10 minutes left, so--
Gosh, urinary incontinence is a super common problem. I think everybody has had some incontinence at some point in their lifetime. It gets to be a problem when it affects one's quality of life and it starts to interfere with your ability to do the things that you want to do.
And so urinary incontinence is defined as, really, the uncontrollable loss of urine. And for many women, it can occur daily or multiple times a day, such that they need to wear protective garments, or pads, or diapers to manage the problem. They might have to change their clothing. It interferes with their ability to work or be intimate with their partner. They feel a little bit more isolated. They don't want to leave the house.
There are a lot of causes of incontinence. The most common types of incontinence that we see in our practice are overactive bladder which is the type of incontinence that makes women run to the bathroom all the time. And they feel like they can't get there fast enough, so they know where all the bathrooms are in their neighborhood or on the way to the store. And they frequently will feel like they can't make it to the bathroom on time before they start to leak urine.
The other type of incontinence that we see here often in our practice is something called stress incontinence, which is a condition where a woman might leak when she coughs, or sneezes, or laughs, or jumps, or exercises. So often that leakage occurs in response to some sort of physical activity. And that can obviously interfere with your desire to work out or engage in certain activities.
And that can result, then, in people not doing exercise and then gaining more weight. And we know that obesity can increase the risk of these problems as well. So it becomes kind of a snowball effect for some of these women.
And luckily, there are many treatment options for dealing with these problems. There is also some less common causes of incontinence, like overflow incontinence, which can occur when you don't empty your bladder completely. There can be incontinence related to mobility issues or dementia in older patients. And so we often look to see what we feel like the underlying cause of the incontinence is when we see our patients, get a better sense of what's causing the problem, how much farther it's causing them, and then what we might be able to do to address and treat the problem for them.
So Dr. Letko, go how common is overactive bladder? It appears to be a fairly common issue. And what can people do?
Well, it's very common, actually. About 17% of population, whether it's male or female, suffer from overactive bladder symptoms. The prevalence increases with age. And as many as 40% of women after the age of 75 suffer from these symptoms.
The difference between men and women is that, actually, unfortunately, women suffer more, because they tend to have more urinary incontinence. So it's more bothersome. Their quality of life is significantly more decreased.
So Dr. Valaitis, you mentioned stress incontinence just a few minutes ago. What are some of the treatments that are possible there?
Right, so again, working with our colleagues in physical therapy can be helpful. So if we can strengthen a woman's pelvic floor muscles, often they'll have better control over their incontinence and might have some alleviation of their symptoms. So we often will send patients to our pelvic floor physical therapists to work with them to help them understand how to use those muscles and go home with a home-exercise program that they'll follow over the course of a couple of months to strengthen their pelvic floor and get better control over their bladder.
There is also some devices that can be inserted into the vagina to provide support to the bladder and perhaps decrease the amount of urinary leakage that occurs. And these are things like a pessary, which we mentioned before can be used for prolapse. And there are special pessaries designed specifically for incontinence that can be placed inside to support the bladder and prevent accidents. There is also other inserts that are developed that can be found at the grocery store in the aisle where pads and things can be found. There are inserts that go in the vagina to support the urethra and the bladder to help prevent accidents.
And then there are some surgical procedures that can be done. Most commonly, the surgery that we do for stress incontinence is something called a midurethral sling, which is a very safe and highly effective procedure that involves placing a small, thin piece of synthetic mesh underneath the urethra. And most commonly, we will then slide that mesh up behind the pubic bone where it will kind of rest with very minimal tension underneath the urethra, be covered by the vaginal wall.
And it'll provide support to the urethra so that when the patient coughs, and bears down, and sneezes, she'll be able to hold her urine. And it won't be leaking anymore. It seems to be quite durable, very effective for managing this problem surgically.
There is also something called a urethral bulking procedure which is a procedure that we commonly do in the office where we can inject-- it's like a tissue filler, very much like collagen and synthetic fillers that are used for plastic surgery to enhance facial features. A similar type of product can be injected into the tissue adjacent to the urethra where it joins the bladder. And we do that by using a little camera inside the urethra to then inject this material under the tissue to provide some bulk there, so that when women cough and sneeze, they're better able to hold their urine in.
And that also works really well. Sometimes it doesn't last forever. And so it does need to often be repeated if it wears off over time.
Oh, that's very interesting. So I did promise before we end the show-- and we've got a couple of minutes left-- I do want to play that third sound bite with Lisa, because it kind of is the culmination of her story. And basically, she talks about how this has changed her life and just the level of care that she received from the physicians and caregivers here at UChicago Medicine.
He she called me at least twice if not more than that. Just, it was so reassuring. He didn't pass it off to somebody else. And he could have. And it would have been fine had he done that.
But I mean, it just really said something to me about how much he cared about me as an individual and as a patient, you know, that he took time out of his very busy schedule to call me and reassure me that we were still-- we were going to have a date set. And you know, everything was going to be fine. And I had never had anyone do that.
And I remember telling him-- and I mean this. I mean every word. He saved my life. It wasn't a traditional life and death type of saving of my life, but he saved my life, gave me my life back.
I really like that, because again, it kind of stresses the quality of life and how important this care is that your team does. And I think it's fantastic. A couple more quick questions to get to, then I'll let you go-- and Dr. Letko, let's start with you on this one. Just talk about the strengths of the University of Chicago Urogynecology group, because obviously, this is a really good team.
Yeah, well, I guess what's set us apart from other groups, that we have experience in taking care of really complex patients. And for this reason, there are other centers that send difficult and complex patients to our institution. And we're also-- I mean, as a University of Chicago, we're involved in the education of students, medical students, residents, fellows, but we are very, as a group of physicians and nurses, we are very involved, deeply involved in the management of the patients and personally provide the continuing care. So we follow very thoroughly. And I think that's a little bit different compared to other places.
And Dr. Valaitis, I'm going to have you end us. But talk to us a little bit about care during the pandemic, because that's on a lot of peoples' minds. Is it safe to come and get care for these conditions? Which, I know it is. But you can talk about that a little bit more. And we don't want people, obviously, to put off their medical care, because they shouldn't have to live with conditions that can be cared for.
Absolutely. I'm so glad that you brought that up. So many of our patients are older, because these problems do tend to affect women that are of a more mature age. And many of them are a little nervous to leave the house for fear of exposure. We're very grateful that the vaccine is coming out, and that it's safe, and that our patients are now being able to have access to it. So that'll make things a lot easier and put people at ease.
But I'd also like to say that the University of Chicago has just done an absolutely incredible job of managing our care of patients during this pandemic, especially providing a safe environment in which we can see patients and take care of them. And I am in the clinic every week. I'm in the operating room every week.
And I can attest to the safety, the cleanliness, and extreme care to which we manage our patients to make sure that we prevent any kind of spread of the virus and provide a safe environment for patients to be seen in and have their surgery in. I myself have not had any exposure to COVID and have tested negative the whole time. And I think that's an attestation to the safety of the environment that we work in and also the safety of the environment that we provide for our patients. So it's very safe.
And actually, we don't want people to neglect their care. I think all of us have seen examples of patients who have waited far too long to manage this problem. On average, women will wait at least five years before they seek care for pelvic floor disorders of any kind. And that's a long time to be feeling isolated, and distressed, and self-conscious, and socially distant from people that you want to spend time with because of a condition that's highly treatable.
So I just want to stress the importance that we are here for people who suffer from this condition. We have so many things to offer our patients. And the environment that we provide for you is very safe, clean, and extremely safe as far as this pandemic goes. So we encourage people to come out and seek help from us.
Well put. And thank you so much for sharing this important information for-- with our audience. We certainly appreciate it. And thank you to our viewers today.
Please remember check out our Facebook page for our scheduled programs that are coming up in the future. And to make an appointment, go online to uchicagomedicine.org. Or you can call 888-824-0200. Thanks again for being with us today. And I hope everyone has a great weekend.
One in three women will experience a pelvic floor disorder. This condition can often cause great discomfort and embarrassment, keeping many women from participating in activities they enjoy.
At the University of Chicago Medicine, our specialists uses a personalized approach to evaluate and treat pelvic floor disorders in the least invasive and most comfortable way possible. Learn more as urogynecologists Sandra Valaitis, MD, and Juraj Letko, MD, discuss pelvic organ prolapse, urinary incontinence and other important information about pelvic floor disorders.
Juraj Letko, MD
Juraj Letko, MD, is a urogynecologist — an obstetrician and gynecologist with advanced training in female and reconstructive surgery. Dr. Letko treats a wide range of conditions, including pelvic organ prolapse, urinary incontinence, urinary infections, and painful, irritative voiding disorders.
Sandra Valaitis, MD
Sandra Valaitis, MD, is an expert in treating women with pelvic organ prolapse, urinary incontinence, and other disorders of the urogenital system. Her areas of interest include suburethral slings, complex reconstructive pelvic surgery, robotic surgery, repair of genitourinary fistulae, and the treatments of mesh complications and erosion.Read Dr. Valaitis' physician bio