All About Pelvic Floor Disorders
Prolapse. Fecal incontinence. Constipation. While these issues may be uncomfortable to discuss with friends and family, listen as Sarah Vogler, MD provides insight into these disorders, discusses treatment options, and shares what's on the horizon for pelvic floor care.
All About Pelvic Floor Disorders
Scott Steele: Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.
So hi everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I'm very pleased to have Dr. Sarah Vogler here, who is the Section Head for Pelvic Floor Disorders in the Department of Colorectal Surgery in the Digestive Disease and Surgery Institute here. We're going to talk a little bit about pelvic floor disorders. Sarah, welcome to Butts & Guts.
Sarah Vogler: Thank you. Thanks for having me.
Scott Steele: So for all the listeners out here, we like to start off with just 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.
Sarah Vogler: I grew up in Cincinnati actually, and then I did my colorectal training in Minnesota, where I was at the Pelvic Floor Center there. And then I came here to start more of a Pelvic Floor Center here.
Scott Steele: Well, we're really excited to have you here. So back in 2018, for all our listeners, we discussed a little bit about pelvic floor disorders on Butts & Guts, but for the listeners who don't remember that, or our new listeners, just give us a general overview first of kind of what is the pelvic floor. What do we mean when we talk about the pelvic floor, before we go to the start, set the baseline for our listeners.
Sarah Vogler: So the infamous pelvic floor. So in my world, the pelvic floor mostly means patients that are coming in with prolapse problems or incontinence problems. They tend to like to use the phrases rectocele, cystocele, enterocele. So they know their celes. They have difficulty evacuating or they can't stop evacuating. Those are their main complaints.
Scott Steele: And so what type of anatomically, the muscles and the things are we talking about there?
Sarah Vogler: So these are your pelvic floor muscles that control your continence. So how well you can control going to the bathroom, how much time you have to get to the bathroom. Some patients have injured these muscles through childbirth. Other times it's just simply age or genetic predisposition to having stretchy pelvic muscles, which will lead to difficulty with continence or constipation.
Scott Steele: So I'm a listener at home and I'm thinking to myself, god, I might have something going on there. A couple of things. First, myth or reality. Pelvic floor disorders can only happen with women.
Sarah Vogler: Myth.
Scott Steele: So men can have pelvic floor disorders?
Sarah Vogler: They can, but they're lucky to have a prostate. So normally things don't fall out.
Scott Steele: So what type of symptoms would somebody experience? I mean, they may have been told, but if you've not wanted to see a doctor, you don't really know, what kind of symptoms do all of these things kind of fit into? I know there's some varying ones, but what are the most common ones?
Sarah Vogler: Well, and so most women have these symptoms and just kind of brush them off and think not a whole lot of them. And it is true, your diet can fluctuate these symptoms, but if you're having symptoms of pelvic pressure, irregular bowel habits that bother you on a daily basis. You won't leave your house until a certain time of day because you have to go to the bathroom five times. Things that are inhibiting your daily lifestyle, as far as your bowel or bladder symptoms, are probably related to a pelvic floor problem.
Scott Steele: So are there risk factors or people that are, you mentioned a little bit of it, but are there risk factors that kind of promote pelvic floor disorders, or is this something that people are born with, or is it acquired over time? Is pregnancy a factor of this for women, or how does this all kind of combine together to result in pelvic floor disorders?
Sarah Vogler: So all of the above. So everybody has a pelvic floor, so everybody's at risk. Certainly if you've had children, vaginal deliveries are a risk for having some sort of injury to the pelvic floor. Some people are just born with stretchier tissues, connective tissue disorders. Those patients will show up with pelvic floor problems younger in life. So it doesn't necessarily mean they've had to have children, but they can have some lack of strength down there that's causing these difficulties. Men, there's not really a certain predisposition to it. They will typically show up having a history of straining a lot and difficulty with bowel habits, but not a specific type of problem that they'll show up with.
Scott Steele: So if somebody just has constipation, we hear that all the time. I got constipation. First of all, what does that mean? And then second of all, does constipation equal pelvic floor disorders?
Sarah Vogler: No. Constipation is different for everybody. Most men will call themselves constipated if they haven't gone to the bathroom by noon some days, and most women will say they're constipated if they haven't gone all week. So it's variable. I think constipation means if you are uncomfortable and not being able to pass stool, then you're probably constipated. The easiest way to treat that is to simply take something that helps things move through your colon at a little bit faster rate. And that means you don't have a pelvic floor disorder. You have a pelvic floor disorder if you're actually getting the urge to go to the bathroom and you can't make it there on time, or you go and nothing can come out. That's more classic of some sort of prolapse symptom or a lack of strength down in your pelvic floor.
Scott Steele: So walk me through as a patient. I see my primary care doctor, I see a gastroenterologist, and I'm told that I have a pelvic floor disorder, one of the celes, or constipation, or whatever, and they come to your clinic. That could be very scary, I think, to come to a colorectal surgeon's office, and especially if it's something with pelvic floor. So walk me through what is that visit like, what is a pelvic examination like, what does this all entail?
Sarah Vogler: So for women it's pretty common that they've seen a gynecologist at some point. So it's very similar to that. Most of the visit is focused around gathering the history and trying to tease out is this an actual surgical anatomic problem, or is this simply something that's functional because of their diet or habits that they have. The exam itself is pretty simple. It's a rectal exam. So nothing fancy, and they've probably already had a gynecologic exam. And then there are certain tests that will help determine specifically how much strength they have in their sphincter muscle, in their pelvic floor muscles, if they're coordinated when they try to evacuate, and even an X-ray study that actually will watch them evacuate to see what happens up on the inside.
Scott Steele: Okay, so let's walk through each of those. So first of all, there's a couple of things that patients may get a list, and they say you're going to get a manometry, or you're going to get an ultrasound, or you're going to get a defecography, either by traditional means or an MRI. Walk the listeners through each one of those,
Sarah Vogler: So none of these are intimidating tests, although when you get this list of tests, I think most people are automatically intimidated by it. But if you think about it, doing a digital rectal exam is not a very scientific way to determine how much strength or coordination is happening in the pelvis. So manometry is simply a small probe that goes in the anal opening and it will measure specifically the strength in the anal sphincter muscles. And then you can do an EMG recruitment, which will show how coordinated those muscles are. So when you try to evacuate, are the muscles helping you, or are they hurting you? And the defecography X-ray is about a two minute test if you're doing it just fluoroscopically, not the MRI, where contrast is put up vaginally and rectally and then you're asked to evacuate it.
That test sounds crazy and it may be the most intimidating. It's probably by far the most helpful to me, because I don't have X-ray vision. So when patients come in and tell me, "This is what I do in the bathroom," and they're describing toilet gymnastics and all these crazy things, that is the test that will help me see what's happening on the inside that's causing them to have difficulty in evacuating.
Scott Steele: So one of the things you talked about is that some of these conditions can occur with time. And so let's just say I'm at home, I'm listening to this and I don't necessarily have some of these symptoms. Should I go into my doctor and get one of these tests or something done, or can I just live my life and go on about things?
Sarah Vogler: I would say mostly live your life. So you can see your primary care physician, work on things like diet and exercise, strengthening. Yoga's a great thing to do for your pelvic floor. But most of the time these symptoms, when it comes to seeing a surgeon, are things that are really problematic on a daily basis. So you don't need to do anything prophylactically to necessarily avoid having these problems. But when you start noticing, I've talked to two or three doctors about this, it's really bothering me on a daily basis, that's when it's time to probably step it up and get some of the tests done.
Scott Steele: So let's walk through just a couple of the more common type diagnoses and how your approaches to maybe treatment of them. So let's first just take rectal prolapse, where the rectum comes out, full thickness, out of the bottom, hanging out there. But you can push it back in.
Sarah Vogler: So that sounds pretty bad, even though you just casually described it. So when this rectal prolapse occurs, people come in very frustrated. It looks like an alien has just fallen out of their bottom. That typically is not something that just happens one day. You don't wake up and your rectum falls out. So most patients have some sort of a history of feeling like they can't evacuate well. They start to notice tissue, maybe it's hemorrhoids, maybe not. And they notice it's happening every time they go to the bathroom, if they push it back in, and then they come to see me. That is something that has to be fixed with surgery.
There's no amount of yoga and exercises that's going to make your rectum go back to the right place. So we have good ways of fixing that. It's also important to make sure that it's not just your rectum that's falling in your pelvis. So we'll probably do some tests to make sure you don't need other things lifted up in your pelvis during surgery.
Scott Steele: You mentioned that, and just to stay on that topic very briefly, do a lot of these conditions occur with something else? I always tell patients I'm a backdoor doctor as a colorectal surgeon. The gynecological world that you live in, how often do these things occur concomitantly?
Sarah Vogler: Very common. So most patients have symptoms of urinary hesitancy, frequency, incontinence, in combination with bowel problems, either constipation or urgency. And the female pelvis is just this kind of big bowl and it's a domino effect. So typically the bladder kind of falls backwards, the vagina and the uterus falls backwards, and then the rectum just kind of gets smashed down and will either prolapse or fall down in the pelvis. So things can't come out the right way or when you want them to come out.
Scott Steele: So now let's switch topics to fecal incontinence. What does that all involve? Is there degrees of it and how is that typically approached and treated?
Sarah Vogler: So fecal incontinence can occur to anybody. So diarrhea is going to cause somebody to just rush to the bathroom, and that's not something that we're going to treat surgically. But if you're having urgency, you feel like you're knocking people out of the bathroom. You know where every bathroom is in the Cleveland area. That's the situation where we can start by medically managing your symptoms and see if we can keep your stools a little bit thicker, giving you more time to get to the bathroom. If that doesn't work, then we move you into the surgical treatment category, which first and foremost you have to make sure there's not some hidden prolapse. So more than 50% of those patients actually need a prolapse repair. But those patients that don't have prolapse going on, we also have really good surgical treatment options that are easy outpatient procedures to help give them extra time to get to the bathroom and stop having accidents.
Scott Steele: And what do those involved?
Sarah Vogler: So the newest one is sacral nerve stimulation, which is a pacemaker for the butt basically, that gets implanted underneath the skin, kind of where your pant line is. And it sends signals to your sacral nerves that will improve your overall continence, both urinary and bowel actually. It's an easy outpatient procedure and we can also test that procedure before you have to commit to it. So you get a test phase to see if it's helped to improve your symptoms of urgency and incontinence.
Scott Steele: Shift gears now to, some people call it constipation, some people call it obstructive defecation, paradoxical puborectalis, all these different kind of grab bag terms that go into it. What is that and how do you approach those?
Sarah Vogler: So obstructive defecation, and these are classically patients too, they come in and say it's my rectocele and I can't evacuate because of my rectocele. Or patients that splint. So they put pressure vaginally or on their perineum to help evacuate. Most of the time it's that your pelvic floor muscles when you go to evacuate are for some reason not doing what they need to, and we can find that out during the testing. It's easily treated with pelvic floor physical therapy to retrain those muscles, so that when you push they're right on board with you and help evacuate stool. Rarely do you have to go to a surgical treatment for that, unless the reason they're not working the right way is because of an internal prolapse that's occurring.
Scott Steele: So it's not an uncommon situation where somebody would come to me and they would say, "I was told that I need a colostomy for everything that's gone down there. Is that really the case? How often is that needed? Or it sounds like there's some treatments for a lot of these different ones, of these particular operations, or medical management, that are fairly successful?
Sarah Vogler: It's very rare anymore they have to move to a colostomy. Typically, in looking at over 900 defecographies a year, I've only done two colostomies a year for the last five or six years. And it's the last ditch thing that you have to do. Most patients don't want a colostomy, and most patients don't need a colostomy. So in this age we have really good medications that help move things through your colon at a normal pace, which will help with evacuation. We also have really good means for physical therapy and biofeedback to retrain your pelvic floor muscles to work the right way. And between those two things, you can typically get more regular bowel habits.
Scott Steele: It seems like when we were talking about before, there's a lot of different kind of concomitant things that be going on, that may cross disciplines, from digestive, to urological, to women's health. How do these different specialties here at the Cleveland Clinic come together to treat these patients?
Sarah Vogler: I think these specialties work well here. You'll probably run through these specialties at some point, depending on your symptoms. And we have patients that cross, in no specific order, between the specialties all the time. So I see patients that have commonly seen urogynecology or GI. I also refer to them commonly. So if you show up in one of those specialists' office, you will get sent to the correct specialist to make sure that everything is dealt with appropriately. And if you can have a combined surgery with two of those specialists at the same time, then we can facilitate that too.
Scott Steele: So what advice do you give to patients out there who may be hesitant to bring some of these uncomfortable topics up to their doctor? I mean, it's one thing to say, listen, I'm losing my stool, or I can't hold things in, or I haven't had a bowel movement in two weeks. What advice do you give to patients about that?
Sarah Vogler: So we know that happens. They've actually studied that. And 50% of women will not mention this to a physician. So I think you need to mention it to a physician. If the physician doesn't know how to help you, they do know where to send you. So bring it up with your primary care physician. They'll start with some easy tests and treatment and then refer you probably on to either urogynecology or colorectal surgery.
Scott Steele: So as the Section Head for Pelvic Floor Disorders here at the Cleveland Clinic, what's on the horizon regarding clinical research for these disorders, and what is the focus, or maybe something that you can say, well, we're going to go towards this?
Sarah Vogler: So pelvic floor surgery has changed radically in the last five years. We're much better at it and we can do it minimally invasively. So patients that are older, who have a few medical problems, don't have to worry so much about this being a big, scary surgery. You can have a better quality of life with fairly minimally invasive options. So don't be afraid to go see a surgeon because of that. We're pushing towards that. So having robotic surgeries, which involves very small incisions and an overnight stay, to fix all sorts of different prolapse problems, as well as the outpatient incontinence surgeries. So we'll keep moving in that direction, and that technology is only getting better.
Scott Steele: That's fantastic stuff. So we like to end up with all of our guests, a couple of quick hitters. So first of all, what's your favorite sport?
Sarah Vogler: Running and swimming.
Scott Steele: And what's your favorite food?
Sarah Vogler: Ice cream.
Scott Steele: Oh wonderful. And I have to ask what kind?
Sarah Vogler: Oh, it changes. It depends on the season.
Scott Steele: And then what's a trip, one of your favorite places that you've been to?
Sarah Vogler: French Riviera.
Scott Steele: And your last nonmedical book that you've read?
Sarah Vogler: It was actually Little Fires Everywhere, because I just moved to Cleveland, and it's about Shaker Heights.
Scott Steele: That's fantastic. I think a Shaker Heights author. And then, you're from Cincinnati, you spent some time here in Cleveland in the past, and you're relatively new here to the Cleveland area. Is something that you like about Cleveland?
Sarah Vogler: It's much warmer than Minnesota, where I came from.
Scott Steele: Well, we're very glad to have you here. And so for more information on pelvic floor disorders and treatment at the Cleveland Clinic, please visit clevelandclinic.org/pelvicfloor. That's clevelandclinic.org/pelvicfloor, P-E-L-V-I-C-F-L-O-O-R. And to speak with a specialist in the Colorectal Center for Functional Bowel Disorders, please call (216) 444-7000. That's (216) 444-7000.
Sarah, thanks for joining us on Butts & Guts.
Sarah Vogler: Thanks.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.