The symptoms of Pelvic Organ Prolapse can range from a modest degree of pressure in the pelvic region to organs actually protruding from the body. Fortunately, for many women, prolapse doesn’t necessarily require treatment beyond being careful to avoid things like heavy lifting. And for those who do need treatment, there are a number of options available, ranging from physical therapy to outpatient surgery. In today’s episode, urologist and urogynecologist Dr. Jannah Thompson talks about prolapse and its treatment.
Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians and caregivers, all available at NAFC.org.
This podcast is supported by our sponsor partner, Medtronic, maker of InterStim systems for bladder and bowel control. To learn more about InterStim therapy, visit controlleaks.com.
Welcome back to another episode of Life Without Leaks. I’m your host, Bruce Kassover, and joining us today is Steve Gregg, the Executive Director for the National Association for Continence. Welcome, Steve!
Steve Gregg: Thank you, Bruce. Great to be here.
Bruce Kassover: Thank you. And today joining us is Dr. Jannah Thompson. She’s a board-certified urogynecologist and urologist in private practice in Grand Rapids, Michigan, and she has a particular focus on pelvic organ prolapse, overactive bladder, fecal incontinence and other bladder and bowel disorders. Welcome, Dr. Thompson. Thank you for joining us today
Dr. Thompson: Thank you, Bruce and Steve. Glad to be here.
Bruce Kassover: Now tell us, how did you get into this field?
Dr. Thompson: Well, that’s a question I get quite a bit because when people think of urology, they don’t necessarily think of women patients or female patients. And so it was somewhat of a circuitous route. I really started in urology because it became clear in medical school that I liked surgery and I liked being able to see something that needed to be fixed and being able to fix it versus more long course conditions, which is funny because those are pretty much the types of conditions I treat now. But that’s what got me into urology. But then once I was in urology, I noticed that there were many female patients, and this was not clear to me as just someone kind of entering into medicine in the medical field, and I wanted to really understand how I could treat them or care for them better, because it didn’t seem that in sort of a general urology residency there was much focus on that. And so that eventually led me to get a fellowship, or to do a fellowship in urogynecology because I really wanted to be able to treat my female patients better with more understanding, advanced knowledge, surgical skills, and that’s really what I obtained in that fellowship. So yeah, kind of in a unique route to get there as a urologist, but also a unique perspective.
Bruce Kassover: So what really is the difference between a urologist and a urogynecologist?
Dr. Thompson: Well, “urologist” is quite a broad field. There’s anything from, you know, oncology, like prostate cancer, testicular cancer, bladder cancer, to conditions like erectile dysfunction and urinary issues. But it really spans into pelvic health issues that might affect women such as urethral diverticulum or urethral cysts, or incontinence, stress incontinence, urge incontinence. So it’s really quite a broad field, but within that there are many areas where you can sort of sub-specialize. I could have gone on and really specialized in just prostate cancer, but as a urogynecologist, I specialize in the treatment of women who have prolapse, incontinence, overactive bladder, bowel incontinence, and so that is really where my focus has, or my practice has really focused, is really treating women with those conditions.
Bruce Kassover: You mentioned pelvic organ prolapse and we spend a lot of time talking about things like overactive bladder and forms of bladder incontinence. One of the things I don’t know if we talk as much about as we should is pelvic organ prolapse. Maybe you could tell us a little bit more about that, how it presents itself, how it gets diagnosed, what’s the nature of it?
Dr. Thompson: Well, pelvic organ prolapse has many names. Patients may have heard things like cystocele, rectocele, uterine prolapse, but essentially it’s a condition that affects over 3 million women in the United States, and it has to do with organs coming out of the body or prolapsing down.
So whether it’s the vagina, the uterus, many people refer to it as sort of the bladder coming down or the rectum, which is partially right and partially incorrect, but it has to do with things protruding or herniating out of the female pelvis. There are muscles and ligaments in our body called the pelvic floor, and I think of them as like a big bowl that sits under the bladder, the vagina and the rectum.
And those attachments can become weakened, deeper attachments in the pelvis to the uterus can weaken, and so what happens is the vagina starts to fall down. I like to describe it to my patients as the vagina’s kind of like a sock, and it’s as if the toe of the sock is trying to come down and out the end almost like you’re going to turn it inside out.
That’s essentially what’s happening. The bowel and the bladder are always either above or below the vagina, so the vagina has to come out first. And so when we’re looking at treatments, treatments are really about supporting the vagina. There’s usually no suturing or tacking up of the bladder or the bowel. It’s really trying to get that vaginal wall back where it is, and then the bladder in the bowel sit where they should be.
Bruce Kassover: Is there any typical demographic that tends to experience this more often? Age or maybe some previous, you know, conditions or experiences that might make one more or less likely to experience this?
Dr. Thompson: Yes, age is definitely a factor. Most women that come in to see me with this are 50 or above, but I do have women, particularly post pregnancy, there’ll be a smaller number of women that’ll experience this. Usually it’s transient, but sometimes it does persist or stay chronic and they seek treatment, but usually age, definitely after menopause, that seems to be a risk factor for it. Pelvic surgeries or even pelvic tumors can play a role, obviously pregnancy and childbirth, so even if a woman has a C-section, it doesn’t necessarily protect her from the condition of prolapse. It could just be the pregnancy itself. Things I think that are really important though that women might notice in their day-to-day life would be chronic constipation, chronic coughing or even heavy repetitive lifting.
You know, I see women that are mail carriers or work on a factory line and they’re having to lift heavy boxes, move heavy things, and that can be the thing that starts the symptoms occurring. Many times actually, they will come in and say, they can tell me an instant or a, or an actual event that happened, and after that they felt the prolapse.
Bruce Kassover: That’s interesting. Are they often surprised by the diagnosis? I mean, how comfortable are some of the people you treat with their own anatomy and understanding what’s going on? Is this, is this sort of like your, you know, sometimes you’ll see a new commercial for a new medicine that treats a disease you’ve never heard of before. Is this one of those situations for a lot of patients, or do most people seem fairly educated about what’s going on?
Dr. Thompson: I think in general, women unfortunately aren’t very educated about their body or their anatomy, and I think that’s because they have never really been given a lot of formal education about it.
It’s gotten better over the years, but I still think that it, the female pelvis is pretty much a black box. By the time they get to me, they’ve seen their primary care physician who’s usually at least labeled the condition, You know, prior to that, I don’t know how familiar they are with it. Some women will end up in the emergency room scared about it because they have no idea what’s happened or, you know, if whatever they’re seeing bulging between their legs is going to fall out, honestly, but, in general, they have sort of a label, but I don’t think a real familiarity with what the actual tissue is that they’re feeling.
And so that’s where I, really, I guess in my practice, one of the things that I try to do to create sort of a unique perspective or a unique experience for the patient is I really spend a lot of time explaining to them what their anatomy is. I draw them pictures, which if any of my patients are listening to this, they’ll laugh at that because they’re these hand drawings, but I find them to be a little more helpful than the animations that I found online.
I think it’s really important that women have a sense of what’s happening to them or framework so that they can then use that visual perspective to really make a decision on what they want to do.
Bruce Kassover: I would imagine that for some people, when they start to see some of the symptoms that you’re describing are really petrified that there’s something horrifically wrong with them. Do you get a lot of people who are in a total panic?
Dr. Thompson: Yeah, I mean, and I guess I didn’t say that. You know, the common symptoms are they feel pressure or they feel a bulging. And I’ll actually ask them, “Do you feel tissue? Do you feel something coming out from between the legs or out of the vagina?” Because that’s usually the symptom, if you really get down to the nitty gritty. You can have pressure or the sensation of pressure in the pelvis for a number of reasons, one of them being prolapse, but there are others. But that sensation of tissue is very unique. So is the sensation of needing to help assist emptying the bladder or the bowel by putting their hand down near the vagina or the rectum because they have to sort of reduce that bulge in order to be able to evacuate the bladder or the bowel.
And so sometimes when I ask them that, they are horrified by the idea that, you know, somebody would do that or even maybe not horrified, but they’re just, they, it never occurred to them that they could do that, but they will notice when they urinate or try to have a bowel movement, that it becomes more uncomfortable to do. And so when we’re talking about it, I just try to be as descriptive as possible so that I make sure I get a clear picture of what’s happening.
Steve Gregg: Dr. Thompson, one of the things that we are currently exploring is underserved populations and try to get them the care that they need, but many of them don’t know where to go. Are you seeing sufficient numbers of those underserved populations? We we’re seeing this in the African American population for sure, maybe to some degree LatinX. Is this condition as prevalent within those populations and are they getting the care that they deserve? And if not, what could we do about that?
Dr. Thompson: Those are great questions, Steve, because they’re questions I’ve asked myself. I do see a diverse population, but not one that represents what we know to be the prevalence. So in Grand Rapids, Michigan, we have a fairly large Hispanic population, and so I do see Spanish speaking patients, which obviously presents another challenge because I don’t speak Spanish.
And so when you’re talking about complex anatomy and complex treatment choices, you know you’re relying on interpreters and, you know, if I sense an uncomfortableness using an interpreter, I imagine the patient does, because I often don’t know whether everything that I’m trying to communicate is getting across because of just differences in words between language or how things are expressed.
But with the African American population, I really do not see very many women in this population, and it concerns me. I’ve reached out actually to patients of my own to say, “how could I try to attract more patients like yourself, how do I get the word out?” I’ve put posters actually in some hair salons locally because I don’t know how to get that word out.
And I know that women, African American women, have this issue. I don’t know where they’re going. It’s possible that because OB-GYNs tend to see a lot of these patients, not just primary care, that they may be staying with the OB-GYN. They may be choosing more conservative options and not always needing surgical options and are not wanting them, but it is a real issue. I think things like podcasts can be helpful, but really being able to find a way to get into the communities where these women are at, whether it’s health fairs or places where you can have these open discussions, I think that that would be very well accepted, but just trying to maneuver to those places or where the best location would be to get the word out, it’s difficult.
Steve Gregg: Yeah. It does represent a challenge. We’re looking at a couple of options and hopefully we can find a way to encourage those that are looking for help to not only find help, but to find the right help. You know, so we know on the bladder related issues, so many folks go in to see their primary care that may or may not get diagnosed…We’re trying to find ways that we can actually get ’em to you, where you have both more time, more understanding of what the treatment options are, and then can put together a really nice treatment plan with the patient’s input, but that still represents a challenge.
Dr. Thompson: Well, one of the unique things about my practice that I started here in 2010 is that I’m the first female-trained urologist/urogynecologist in West Michigan. And with that, I knew women were going to come to see me and I wanted them to feel comfortable. So I’m surrounded by an all-female staff, but with that, I have a navigator who is native speaking Spanish because it’s very important to me if we’re going to have a navigator who’s calling patients on the phone, that we’d be able to try and access as many of our patients as we can, but also having African American staff, like physical therapists and surgery schedulers because I do want to create an environment in which everyone feels welcome and it’s important to just have different perspectives around myself so that I can administer the best care possible. And that definitely includes the team of people that I have with.
Steve Gregg: What would you recommend if a woman starts to think that she has one of these problems? It could be SUI, OAB or a little bit of pelvic organ prolapse. What should she do first?
Dr. Thompson: You mean, which should she see treatment on first?
Steve Gregg: So what we find, or most people don’t really know what’s occurring with their body, and you’ve talked about that.
So you start experiencing symptoms. That’s oftentimes when people come to us like, What is this? And we help educate them along the way. We then try to push them into who to talk to and even how to talk to. But you certainly go out and you talk at health fairs, and so if somebody will come up to you and say, Well, I got this little problem and I don’t know whether it is, and I don’t know whether it’s a big problem, I don’t know if it’s a little problem, what do I do?
And so what do you encourage them to do first?
Dr. Thompson: Well, I think first, you know, getting that education is most helpful and whether, you know, they find that education online, there are great resources online, just not everything you find online is helpful. Or whether they ask their primary care to send them to a specialist so they can get that knowledge, I think is very important.
A lot of times, women come to see me with a symptom and they just want to know that it’s not something harmful, or if they ignored it something could get worse. So a lot of times after I educate them about what’s going on, they choose to observe it, or now they know what signs to look for if it does worsen, and the fact that they can come back to me and usually haven’t done something that, you know, we can’t decide to start treatment at that point. So I do think education is, is key. So things like podcasts or going to websites like my own or Mayo Clinic, University of Michigan, sort of big universities usually have a lot of education buried in their websites on different conditions to at least start.
Bruce Kassover: When they, when they do get to you for, for a consultation, what sort of treatment options are available for pelvic organ prolapse?
Dr. Thompson: So for pelvic organ prolapse, the first thing that I want them to know is they can choose to do nothing. So it is very rare that there is prolapse that can be causing a medical condition that they do need to treat.
And I talk to them specifically about that, if it applies to them, but usually they just need to know about it. We talk about how bothersome it is. So one of the other things that’s important to me is understanding what the patient’s goal is. You know, what is it that they are being limited from doing or restricting themselves from doing, because that helps us shape what their unique treatment goal should be.
So if a patient is bothered by prolapse, there are things like physical therapy, pessaries and surgery. Now, physical therapy is also an area where I think that not all physical therapists are the same, and there are specialized physical therapists that handle just pelvic floor disorders, and that’s more than just your average Kegel or strengthening exercises that you may have been told to do.
And so for certain women, that’s appropriate to, to seek out physical therapists to help prevent the prolapse from worsen. Pessaries are an inserts, similar to a diaphragm. I think of them as sort of silicone circular shaped devices that are fit to each woman specifically, and they basically hold the prolapse up, they’re inserted in the vagina and they basically raise up that bulge or that tissue.
And then finally, surgery. And surgery can be done a number of ways, but all of them are currently outpatient surgeries and have a period of time where they do need to limit activities. My personal perspective is that they don’t have to limit them lifelong, but if a woman is, you know, routinely lifting 50 pounds or more, or a job where she’s doing that, I do counsel them that that can increase their risk of the prolapse coming back. But outside of sort of the six to eight weeks, the activity restrictions, most women can go back to, you know, more strenuous physical activity, swimming, they can go back to sexual intercourse after four weeks, things like that.
Bruce Kassover: So it sounds like a pretty good prognosis overall then.
Dr. Thompson: Mm-hmm…Mm-hmm…Now most women are scared of surgery. I think, I think there’s probably two camps where they either come in and that’s what they want to do. They want to get it taken care of. But there’s other women and, and I would say at least 50% who are a little wary of surgery. I think they’re concerned about, you know, risk-benefit. You know, is this going to take care of it? I don’t want it to come back. I would prefer to try more conservative routes first, and I always encourage that because even if the more conservative routes such as physical therapy don’t completely resolve the symptoms, it definitely gives great foundation, great education about their body exercises to fall back on after surgery, to continue to sort of keep a healthy pelvis over time.
Bruce Kassover: Well, Dr. Thompson, thank you. This has really been enlightening and I appreciate your insight and your perspective on pelvic organ prolapse, and we hope, and certainly anybody out there who’s experiencing any of these symptoms actually goes and reaches out to physicians so they can find the help that they need.
Life Without Leaks has been brought to you by the National Association for Continence. This podcast was supported by our sponsor partner, Medtronic, makers of the intersystem systems for bladder and bowel control. To learn more about the intersystem systems, visit controlleaks.com. Our music is rainbows by Kevin McLeod and can be found online at incompetech.com.
Music: Rainbows Kevin MacLeod (incompetech.com)
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