Multicompartment Pelvic Organ Prolapse

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end-to-end.

Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Today I'm extremely pleased to have a new guest and a second time guest here, going to talk about multi-compartment pelvic organ prolapse.

First, the second time guest part of our colorectal surgery department, Dr. Anna Spivak. Anna's a colorectal surgeon and she is the Director of the Pelvic Floor Section in the Department of Colorectal Surgery here at Cleveland Clinic. And a first-time guest, Dr. Shannon Wallace, who's a staff physician at Cleveland Clinic's Obstetrics and Gynecology Institute in the Division of Urogynecology and Pelvic Floor Disorders. Ladies, welcome.

Dr. Anna Spivak: Thank you. It's a blessing to be here.

Dr. Shannon Wallace: Thank you so much.

Dr. Scott Steele: Perfect. Again, just as background for our listeners and Shannon, I'll go with you first, tell us a little bit about yourself, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Shannon Wallace: Great, thank you so much, Dr. Steele. My name is Shannon Wallace and I'm a urogynecologist. I grew up in South Africa actually, and I moved to Denver, Colorado. I went to medical school at the University of Colorado and really just fell in love with taking care of female patients and knew I wanted to do obstetrics and gynecology. I moved to the big city of New York and did my obstetrics and gynecology residency at Mount Sinai. They had a great urogynecology team there and I really fell in love with the surgeries, with the patients, really with addressing the quality of life issues that these patients have.

I did my fellowship in urogynecology at Stanford, California, so went to the other coast, and was there for three years and met Dr. Brooke Gurland, who was once a faculty member here at the Clinic. She's a colorectal surgeon who became my mentor and really opened up this world of multi-compartment prolapse and how it affects women and how it's really sort of underdiagnosed and undertreated. This became a passion of mine. When I came to the Cleveland Clinic, I was lucky enough to meet Dr. Spivak And the two of us really have a passion for taking care of these patients and sort of started a multi-compartment clinic and multi-compartment surgical practice here.

Dr. Scott Steele: Fantastic. Anna?

Dr. Anna Spivak: I was born in St. Petersburg, Russia, so we make a very international team between Dr. Wallace and I. I came here as a teenager and lived in New York City for many years and then went to medical school in Philadelphia College of Osteopathic Medicine. I did my general surgery training there as well in Philadelphia. Then I went to Allegheny Health Network, still stayed in Pennsylvania for colorectal fellowship training and then started the job and did many all things colorectal, but always had passion for pelvic floor. I find it one of the most challenging parts of colorectal surgery. Then Dr. Steele recruited me to come to the clinic and sort of took on the pelvic floor as a majority of my practice. Very fortunate to work with Dr. Wallace and have multi-disciplinary clinic and take care of patients with pelvic floor issues.

Dr. Scott Steele: Well, that's fantastic. Today we're going to be talking about multi-compartment pelvic organ prolapse. To start Shannon, give us a little bit of a high-level about what does that mean?

Dr. Shannon Wallace: When we talk about multi-compartment prolapse, what we're really talking about is weakness of the pelvic floor that causes your pelvic organs to either come through the vagina or through the anus. There are three things in the pelvis. There is the bladder, there is the uterus, then there is the rectum. When patients have weakness of the pelvic floor, those muscles can't support those organs and so gravity starts to work and things fall through the path of least resistance. Either the uterus can come down or the top of the vagina, the bladder can come down through the vagina, and then the rectum can either bulge out through the vagina or can actually come down through the anus. When your muscles aren't strong enough to really hold those organs in place, then you start to feel the symptoms that come with multi-compartment prolapse.

Dr. Scott Steele: Anna, lots of, I imagine, different causes of this, but can you kind of give us an insight in what are the more common ones?

Dr. Anna Spivak: The most common one is actually being a woman and then the next most common one is having pregnancy, especially prolonged laboring and larger babies, including the use of forceps or episiotomies during pregnancy, that can later in life lead to issues with pelvic floor. Obesity is another big one. Connective tissue disorder, we see it more and more and we find that women with connective tissue disorder tend to have laxity in their pelvic floor, resulting in pelvic organ prolapse. Steroid use can be another one that can contribute to that.

Dr. Scott Steele: I've heard it said that as you get older, just everything starts falling down. Is this part of just the natural evolution of people getting older or is there ... Risk factors, I understand that, but can most people expect some of these things to occur as they get older?

Dr. Anna Spivak: Things do drop down as people get older, but it doesn't necessarily need to be a prolapse and certainly it doesn't have to be a symptomatic prolapse, which is the most important thing.

One symptom that I didn't mention, which is probably one of the most common ones also, especially for the rectal prolapse, is constipation and straining. Together with perhaps genetic predisposition, connective tissue quality, and some of the other reasons that I mentioned together could result in a prolapse. Then if it's bad enough, it can result in symptomatic prolapse and that's when patients tend to seek care and find us.

Dr. Scott Steele: Shannon, I know we talked a little bit about some of the symptoms that can occur and we talked about multi-compartment. Can you give us a little bit more granular detail about what are these compartments and what are the symptoms that go along with each of the compartments?

Dr. Shannon Wallace: Sure. Yeah, I think that's a very, very good question because when patients come in, there are lots of different symptoms that they could be experiencing. When we ask them questions, those symptoms can really tell us, "Okay, what is the compartment that we feel like is falling? What is the most bothersome thing to the patient?"

Let's start with the compartment that I see the most of, which is really that anterior wall of the vagina, that top portion of the vagina that lifts up the bladder. If you have weak muscles where your anterior vaginal wall starts to drop a little bit and starts to stretch out kind of like a hammock, then your bladder is going to start to fall more into the vagina. Patients will present oftentimes with vaginal pressure, vaginal bulge. They also might complain of not being able to empty their bladder as well as they used to. They may have to put their fingers into the vagina to actually empty the bladder. Sometimes they may even notice that they have little bladder spasms or more urge incontinence, urgency because they really feel like they're not able to empty and not able to go to the bathroom.

When patients have the top portion of the vagina, which is where the uterus is, or if they've had a hysterectomy where the vaginal cuff is, that portion is really supported by the pelvic floor muscles and some strong ligaments. When those pelvic floor muscles and those ligaments get a little bit lax and loose over time, that top portion can really start to fall down and that's going to cause a lot of pressure, a lot of vaginal bulge symptoms. It can cause a lot of pain with intercourse. Patients will complain that they feel like something's in the way when they're trying to have intercourse.

Then we talk about the posterior wall of the vagina, which is really the back wall that's between the vagina and the rectum. When that gets stretched out, you can imagine when patients are pregnant and they're delivering their babies and they're pushing their babies out, that head of the baby comes through the pelvic floor and really stretches out the pelvic floor. We have good data to show that the muscles of the pelvic floor can stretch to three times the length during a vaginal delivery. Those muscles that overlay the rectum really get stretched out and floppy. When patients have a weak back wall of the vagina, really the rectum can pooch in. They'll oftentimes describe that when they're trying to have a bowel movement, when patients are trying to go to the bathroom and they're straining and straining because that rectum is bulging into the vagina and they're not able to completely empty or evacuate. Sometimes patients have to put their fingers into the vagina to actually what we call splinting to actually scoop the stool out and allow themselves to evacuate.

Then we have the rectal prolapse component where patients will have some weakness at the pelvic floor that causes the rectum either to scrunch down on itself, what we call rectal intussusception, or actually where it'll come out through the anus. If patients have that, they'll often have very uncomfortable bowel movements where they have straining, constipation, they may have some fecal incontinence where they notice a little bit of stool or mucus leak out. Then ultimately they might actually have some of the rectum coming out through the anus, which is very uncomfortable, and they may notice it as a red grape-like or even a melon-like feeling on the rectum. Those are the symptoms that we typically ask about when patients see us in the office and that can help us determine what compartment might be the most symptomatic or is prolapsing the most.

Dr. Scott Steele: Fantastic. Anna, truth or myth, truth or myth. Some patients don't have any symptoms when experiencing multi-compartment pelvic organ prolapse.

Dr. Anna Spivak: It could be both. It could be truth and myth, and that actually answers the question, should they be seeking care? If they have prolapse and they have no symptoms, and over time things just drop down, just like you mentioned, maybe part of getting older, they don't necessarily need to have it addressed. Just because somebody did an exam and said, "Oh, things are down," it doesn't mean they need to have surgery and have pelvic floor reconstruction. They can just continue on with the activities of daily living if the quality of life is not impacted. At the same time, most patients, again, who find us are the patients who have significant symptoms and that could be very variable. Some people have very minimal prolapse and the symptoms are severe and some patients can have a lot of prolapse and the symptoms are very minimal, so a little bit of both.

Dr. Scott Steele: I'll give this to the both of you. Shannon, you can start first. What are the benefits of working in a multidisciplinary team instead of one type of surgeon?

Dr. Shannon Wallace: You'll get a biased answer from the two of us, I promise, because we just love working together. One of the reasons that we just really believe that a multidisciplinary approach is the best approach for the patient is because we learn so much from each other. Anna has such an understanding of the pelvic floor perspective from the rectal side, and I have such an understanding of the pelvic floor perspective from the vaginal side, but patients don't just present with only vaginal symptoms or only rectal symptoms. They really present with both. When they present with both, you can talk to each other and figure out the best option for this patient, thinking about the whole compartment and the entire pelvic floor.

The other reason that I really encourage listeners to consider a multidisciplinary approach like the two of us have is that we are able to see patients together. When we see patients together, oftentimes we ask questions that maybe I wouldn't necessarily ask in my normal visit, but because I'm seeing patients with Anna, I may focus more on the rectal side or I may focus more on their history in terms of their defecatory symptoms or their prior imaging. That gives me a very different perspective than if I was seeing patients on my own.

Dr. Scott Steele: Anna?

Dr. Anna Spivak: Yeah, so I'm going to go with a much simple answer. If you have three things, so pelvic floor is a basket, there are three things in there. It's a bladder, a vagina with a uterus and a rectum. If one thing is lifted and the other thing is still down but maybe not as much as the first one was, and you lift the heaviest item, you're still going to feel the next one, so fixing half of the problem. It's not uncommon that even the patients who come to see us, they had maybe had a prior repair for one thing, for middle or the posterior compartment, but the other one is bothering them. What we make sure is that we actually address the whole pelvic floor, the whole problem as opposed to just one thing.

What we also find is that the risk of recurrence can be also reduced if we are lifting one organ and the other organ is still weighing down the whole pelvic organ system, it can also contribute to the risk of recurrence. We do better by lifting everything up at the same time, and we really can give patients a better repair when we reinforce everything together and lift everything up at the same time.

Dr. Scott Steele: Shannon, what questions should patients ask their doctor when exploring treatment? Anna, how can a patient know if reconstructing surgery is the right move for them?

Dr. Shannon Wallace: I think it's very important for patients who are seeing their doctors to ask them the gamut of treatment options. The first place to start is really with their symptoms and their quality of life. We have lots of patients who come in, some who are severely affected by their prolapse and other patients who might have prolapse but are not necessarily as bothered. We have conservative options for patients. There's pelvic floor physical therapy. Patients who have vaginal prolapse are oftentimes candidates for a vaginal pessary. Patients who have bothersome constipation and straining oftentimes with bowel regimens and dietary changes can really improve their symptoms. Patients who are fecal incontinence may also be candidates for a sacral neuromodulation or other options for their fecal incontinence or their urinary incontinence. I think really important is talking to the patient and figuring out what bothers them the most and how does it impact their quality of life. Once you've got an understanding of what is truly bothersome and the patient knows that there are some other options out there and they're still interested in surgery, then you can explore their surgical options.

Dr. Anna Spivak: To answer your question of when is the reconstructive surgery the right answer is really we are looking to improve quality of life. For patients who are symptomatic, we have a very honest conversation with shared decision-making with a patient where we can see what we can do with an operation, and not every patient who sees us is necessarily will do better. That's a shared decision-making and an honest conversation. How can we improve your quality of life and will it be better if you lift things up? Are your symptoms really caused by organs prolapsing? When I'm saying symptoms, I'm talking about things like pelvic pain or pressure. Are they really caused by organs prolapsing or are there other contributing factors?

Dr. Scott Steele: Are there any advancements on the horizon when it comes to the treatment of multi-compartmental pelvic organ prolapse?

Dr. Anna Spivak: When we say multidisciplinary, and you are hearing from the two of us, we really lean very heavily here at the Clinic on also our other colleagues and those with pelvic pain, gastroenterology, pelvic floor, physical therapy, even psychology. The goal is really to address the whole patient and to limit the risks for recurrence. We do know from our data that pelvic organ prolapses tend to recur, so optimizing the surgical outcomes by optimizing the risk factors is the things that we are looking at. We continue to look at improving procedures and just like doing it in a multidisciplinary, multi-compartment approach to really decrease the risk of recurrences in the future.

Dr. Scott Steele: Now it's time for our quick hitters, a chance to get to know you each a little bit better. First of all, to each of you, if I was to turn on your radio, what would I be listening to?

Dr. Shannon Wallace: I'm ashamed to admit it, but probably Taylor Swift-

Dr. Scott Steele: Fantastic.

Dr. Shannon Wallace: ... for all those Swifties out there.

Dr. Scott Steele: Good, Anna?

Dr. Anna Spivak: Not Taylor Swift for sure. You'll probably be listening to classic rock.

Dr. Scott Steele: Fantastic. What's your favorite sport to play or to watch?

Dr. Shannon Wallace: Oh, I'm a huge football fan, but I'm also a huge Broncos fan, so it was very unfortunate to watch the Chiefs win this weekend. Although I am a Taylor Swift fan, so I was very on the fence. I love watching football and then my favorite sport to play is tennis, but now I've been introduced to pickleball, which is the new game in town.

Dr. Anna Spivak: Hm. Well, tennis and gymnastics to watch for me, but we should play some pickleball.

Dr. Shannon Wallace: We'll have to duke it out on the court.

Dr. Scott Steele: Sounds good. Salt or sweet?

Dr. Shannon Wallace: Oh, sweet, all the way.

Dr. Anna Spivak: Oh, sweet, all the way.

Dr. Scott Steele: Then finally, Anna, I've asked you in this the past Shannon, I'll ask you. What is your favorite thing about living here in northeast Ohio?

Dr. Shannon Wallace: Well, I love living in Cleveland because we have four seasons and they're all so different, and I love that the weather changes. We have wonderful summers that are not humid. We have amazingly breezy falls. We have a lovely, sometimes wet spring, and then we have a fun winter where I can take my son to play in the snow.

Dr. Scott Steele: Fantastic. Anna, I guess since I've asked you that in the past, I'll ask you what is St. Petersburg, Russia like?

Dr. Anna Spivak: Very cold in the winter. There are no snow days.

Dr. Scott Steele: Fantastic. To the both of you, final take-home message for our listeners.

Dr. Anna Spivak: Our goal in our practice is to include our patients in the shared decision to improve their quality of life and really come up with an individual approach for each patient and each prolapse or problem individually.

Dr. Shannon Wallace: I agree. I think we see a lot of patients in our practice who have come from many different consultations, have seen many doctors, have done many imaging studies. When they come to us, we try to take a new perspective. We try to listen to their symptoms, figure out what bothers them the most, figure out how we can help with their quality of life. Our goal is really the correct surgery for the correct patient or the correct treatment for the correct patient. Our goal for the future is really to make this multidisciplinary approach a part of everyone's practice because we think that this is the best way to take care of patients.

Dr. Scott Steele: Well said to the each of you. To learn more about multi-compartment pelvic organ prolapse, or to schedule an appointment for treatment at the Cleveland Clinic, please call the Digestive Disease Institute at 216.444.7000. That's 216.444.7000. You can also visit the website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. If you're looking to connect with the Cleveland Clinic, Obstetrics and Gynecology Institute, they can be reached at 216.444.6601. That's 216.444.6601. Ladies, thanks so much for joining us on Butts and Guts.

Dr. Anna Spivak: Thank you for having us.

Dr. Shannon Wallace: Thank you so much, it was great.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.