Pelvic Floor Disorders: Symptoms, Causes and Treatment Options

Dr. Scott Steele:

Butts & 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 & Guts. I'm your host, Scott Steele, colorectal surgeon and President of Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio. And today, it's always a pleasure when I have a multi-time guest, and in this case, a third time guest, Dr. Anna Spivak, who is a colorectal surgeon and the section chief of Pelvic Floor Surgery in the Digestive Disease Institute here at the Cleveland Clinic. Anna, welcome back to Butts & Guts.

Dr. Anna Spivak:

Thank you so much for having me.

Dr. Scott Steele:

So today we're going to talk all about pelvic floor disorders, your specialty. But before we do that, for those who have not heard some of your prior podcasts, tell us a little bit about yourself, and how did it come to the point that you came to the Cleveland Clinic?

Dr. Anna Spivak:

Well, you recruited me to Cleveland Clinic. Dr. Steele brought me over almost five years ago now, and I'm a colorectal surgeon, and I was interested in pelvic floor and he recruited me to do that. And ever since coming to the clinic, I have built a multidisciplinary collaboration and pelvic floor service line. And we see patients from all over the country really with complex pelvic floor disorders.

Dr. Scott Steele:

Yeah, we're so glad to have you here. So we've touched on pelvic floor disorders on Butts & Guts several years ago, but we have a lot of new listeners, so we want to circle back. So give us, if you will, a foundational overview. What is the pelvic floor? And what kinds of conditions fall underneath this umbrella of pelvic floor dysfunction?

Dr. Anna Spivak:

So it's a very broad umbrella for a multitude of diagnoses. So pelvic floor essentially is a basket of muscles that holds organs in place. And from colorectal standpoint, it's rectum, but it also has for women, uterus, and vagina, and bladder and urethra. And everything that affects those organs can really fall into that umbrella. It could be things like prolapse, it could be prolapse of the rectum, but it also could be prolapse of more than one thing, prolapse of rectum, vagina and bladder, or prolapse of one of them. It could also be control. It could also be ability to hold the bladder control, the urine control or control of stool. It can also be ability to get stuff out, because pelvic floor does both. It holds things in, but it also allows for things to get out. So things like obstructive defecation or inability to get stool out.

From urology or gynecologist standpoint, it could also be an ability to empty the bladder also falls into that umbrella. We also treat diseases of fistula when there are holes that shouldn't be there, whether they resulted from childbirth trauma, or from a different kind of trauma, or from some other surgery that's been going on also can fall into that umbrella. Sometimes constipation falls into that umbrella. So it's a very broad name for a lot of different diagnoses, but to all things functionally related to organs that live in the pelvis.

Dr. Scott Steele:

So is this a disease of just one predominant man, women, young, old? Or who's at most risk for developing these disorders? Is there certain populations of people that the listeners might be surprised to learn that are affected?

Dr. Anna Spivak:

We actually see it in all comers. We see it in women, we see it in men, we see it more and more common in younger patients. And one of the things that affects pelvic floor function is ability of the muscles of the pelvic floor, of that diaphragm of the pelvic floor to appropriately relax and contract. And we see it more and more common in younger patients. And I always jokingly say that some women, or some patients get a migraine and some get pelvic floor tension. So it's inability for those muscles to function properly. We see it very, very commonly in younger patients. We see it not infrequently in women after they have babies. And certainly very common in young men, and it's not something that young men think that they may have, but it's not uncommon. And I would say you can see it in the whole spectrum of population because most people think like, "Oh, it's an older women's problems, things are falling out."

But it really affects everybody in all spectrum of population, and can see it just about in everybody. And a lot of times I see patients who were not diagnosed, or didn't know that that's the problem that they have, and for years been treating maybe hemorrhoids, or maybe chronic fissures or just constipation that they keep taking laxatives for and there are really other things have not been addressed.

Dr. Scott Steele:

Anna, you talked in the past about how physical exam plays a large role in terms of the diagnosis of some of these complex or routine straightforward pelvic floor disorders. But are there other diagnostic tests, and maybe some that have evolved in the past few years, some imaging modalities, or assessment techniques that are giving you, the provider, a clearer picture of what's all going down in that region?

Dr. Anna Spivak:

So there's several tests that we do. The most common test that I would say most patients who end up in our clinic end up undergoing, is something called anorectal manometry. It's a fairly simple test that's done in the clinic, and that's an objective measure of pressures, of ability to relax the muscles, of ability to expel the balloon. We also measure capacity of the rectum in that test. Takes about five minutes. It's done by our nurses, and that's a very good objective test that also together with a physical exam gives me a very good idea as to how the organs are functioning, and how the muscles are coordinating in the pelvis. Sometimes patients when we suspect prolapse, internal prolapse or something also called intussusception, the patients would get something called defecography. That is a little bit more annoying test to do, but very, very useful and gives us a lot of information, that is done by radiology.

It's a test when the contrast is placed in the rectum, and the patient sits in the radiolucent commode and they expel it. So we see exactly what happens with the organs in the process of defecation. Some patients sometimes need to get an MRI defecography where we see all the muscles, certain instances like a perineal hernia that might be necessary. Some patients need a gynecologic or urogynecologic evaluation with urodynamics, where the capacitance of the bladder and ability of the bladder to empty is measured. Sometimes we do an ultrasound to assess the muscles, so assess the sphincter complex. So these are all different tests that depending on each particular case could be done in our clinic.

Dr. Scott Steele:

Anna, you mentioned a little bit earlier that patients can go undiagnosed, or not even realizing that they may not even go and get evaluated for a pelvic floor disorder. So is there a moment, whether it be childbirth, or incontinence, or menopause, or major illness that may, if you will, trigger noticeable symptoms? Or is this just something that you got to be aware of it and you can go get evaluated for?

Dr. Anna Spivak

I think it's a little bit challenging because I would say after childbirth, every woman should get evaluated, and it's not something that's very common in Europe. It's not nearly as common here. And our physical therapists here at the clinic have a postpartum program, so that is certainly a big insult on the pelvis, and something that could trigger things both from ability to hold things but also of letting things go. I would say if somebody continues to struggle with pain, chronic things, bad hemorrhoids, fissures, inability to empty, spending a long time on the toilet, that is certainly something that should at least raise the question, is there also an issue with the muscles? It is never normal to leak things. So that certainly warrants an evaluation, and that is applicable to sometimes older patients, younger patients, but it's also applicable to patients that I didn't mention that in one of the diagnosis, but patients who had surgery, patients who had their part of their colon, the part of their rectum out, and now they have a functional problem.

So that also can fall into the same umbrella of diagnosis that we work with.

Dr. Scott Steele:

So I always tell our trainees, never forget that you're just meeting some of these patients, and all of a sudden they're examining a very private portion of their bodies. And so there's probably some listeners out there that are a little bit worried about what's it like to go in and see a colorectal surgeon. So when a patient comes to see you at the Cleveland Clinic for this, what does that initial evaluation look like? What should somebody expect from a pelvic floor exam? And is there anything they can do to prepare?

Dr. Anna Spivak:

So it is a very intimate and very personal exam. And certainly in some of our patients who maybe underwent some trauma in the past, that can be incredibly uncomfortable, or even patients who have very tight muscles can be incredibly uncomfortable, and we recognize that and do everything possible to make the patient comfortable. It's an exam that we take time with, make sure explain everything to the patient, never try to intentionally hurt anyone. So it's an invasive exam, but we try to keep it comfortable. And it doesn't start with exam. It starts with talking about symptoms, and talking about prior testing, a workup or a treatment that was done, and then we move up to the part of the exam. If the patient is undergoing manometry at the same visit, they would be asked to do an enema, and that is to get the best possible study on the manometry visit, and try not to stress about it and keep an open mind.

Dr. Scott Steele:

And then even without symptoms, should people be proactive about their pelvic floor health? And is this age limited? Or a life stage when we're asking about a pelvic floor evaluation where that makes sense?

Dr. Anna Spivak:

Absolutely not age limited, can come at any age. I think for women after childbirth, they have to be proactive. For aging patients, postmenopausal patients, keeping their pelvic floor strong, exercising it, keeping just the same way you exercise the entire body. Those are some of the thinner muscles in our body that start to go early, and keeping a healthy weight. Those are all things that can contribute to pelvic floor dysfunction, but also avoiding constipation, remembering screening colonoscopies, all the things that we usually think about in the preventative health.

Dr. Scott Steele:

So now let's switch gears a little bit and talk about the treatment of these pelvic floor disorders. And I know that it's a wide spectrum here. So to a certain degree, walk us through a little bit of that. So from pelvic floor therapy, biofeedback, medications, to surgery and what that involves. So how do you make a path forward for some of these patients?

Dr. Anna Spivak:

So I would think about it from a different kind of standpoint. So we have anatomical problems, and I've mentioned that some of the things that we see in pelvic floor is prolapse. And then we have problems with maybe muscles being too weak, or too strong and not coordinating properly. And then we have certain conditions where maybe it could be a neurological problem. So let's start with the simplest. So not simplest, it's actually the most difficult one to treat, but something that requires the least invasive treatment. So the muscles are too weak, muscles are too strong, things are not coordinating properly. So these are the patients that most of the time would start with pelvic floor physical therapy.

And that is, again, something that we are very fortunate to have a fantastic program here at the Cleveland Clinic, but it is, again, it's a therapy that involves a fairly intimate kind of workup and treatment. It requires a trust and communication between therapist and the patient, and patients buy-in into just trying to get better, and retrain some of the things, and strengthen some of the things, some of the muscles that they haven't done in maybe ever. And then in certain patients where it could be that the muscles are still not pliable enough, or too strong, or not relaxing, in certain cases we would consider doing injections of the pelvic floor. It's usually not a starting thing, but it's usually in conjunction with pelvic floor physical therapy. That could be something that we offer and a modality that would be necessary. And then for things like incontinence, we have implantable devices like a pacemaker of the pelvis, that can help give an extra signal for control of the bladder and the bowel.

And then moving on to surgeries, it's variable what the problem is, and whether it's things that need to be suspended, or it's a surgery if it's for constipation, which part of what is not working? Is it the constipation that is because there are certain things that are prolapsing on the inside? Or is this constipation and sort of constipation in the pelvis? Or is this, things that are not working in the belly? In those cases, we will be working in very closely in collaboration with gastroenterology, but the surgery is very variable, whether we are addressing the pelvis or both or the belly, whether it's the fistula. We do a lot of our surgery robotically here at the clinic and for this indication. And in the cases of prolapse, I collaborate and work very closely with urology and urogynecology to get everything addressed at the same time.

Dr. Scott Steele:

You mentioned robotics and minimally invasive surgery. So obviously that's advanced lots of different disciplines significantly and especially in colorectal care. So for your pelvic floor patients, how is the minimally invasive approach, whether it is laparoscopic or robotic, helped out in terms of outcomes, recovery? And is there somebody that's not a candidate for surgery? Or not a candidate for minimally invasive surgery? Or has the advance of laparoscopic or robotics allowed us to take on more complex patients?

Dr. Anna Spivak:

Absolutely. I would say that the only limiting factor would be a really medical stability of the patient, the ability to tolerate surgery and anesthesia. Minimally invasive surgery allows us to do more challenging cases with small incisions, faster recovery. Oftentimes these patients go home the same day, require minimal pain medication, return to the activities of daily living a lot faster, and we are able to treat most diseases this way. And I would say that if the patient had multiple, multiple prior surgeries, we will usually try. Sometimes it's not possible, but in types of surgeries that I do, I would say at least for prolapse surgeries, most of our surgeries are done robotically and patients can go home the same day or the next morning, take very minimal pain medications, able to return to activities of daily living. And considering the amount of surgery that is done, it's truly remarkable how quickly they can return to their function.

Dr. Scott Steele:

So can lifestyle changes, diet, exercise, weight management, breathing techniques, can they genuinely impact pelvic floor health? And what do you tell patients who want to be proactive and avoid any sort of operative interventions?

Dr. Anna Spivak:

I'd say the biggest thing is have good bowel habits, and good bowel regimen if that's needed. Avoid constipation, stay hydrated, keep an active lifestyle, have a healthy weight, a healthy balanced diet and good exercise routine. I would say that pelvic floor physical therapy does tremendous effort for patients, whether it's after childbirth, after pelvic trauma, whether it's somebody with minimal amount of leakage that they just started having those symptoms and need help strengthening those muscles. And it might not be available for everybody, especially if patients are outside of Cleveland, or in areas where those therapies are not available. There is quite a bit of that information online now, and the idea is that be aware of it, and just like everything in the body needs exercise and like you said, diet and healthy lifestyle and mostly keeping healthy habits, not being constipated, not sitting on the toilet for too long.

And if there is an injury, or if there is a inciting event really seeking care and not waiting for a long time, that's important.

Dr. Scott Steele:

Despite the prevalence of what this is, it's still a topic that many people are completely embarrassed to bring up even with their own doctor. So what do you say to those patients that are maybe quietly living, but significantly impacted with leakage, or prolapse or constipation? Is there a cost to waiting?

Dr. Anna Spivak:

It's a quality of life. It's ability to do things that you want to do. Not infrequently I have patients who tell me that they modify their entire day and activities around their bowel function, around leakage, or not able to participate in things that they like to do. And we are fortunate to have treatment for those things. And I think if you have an issue, and yes, it might be embarrassing, but this is what we do day in and day out, and see hundreds of patients with these kind of problems and hopefully we can help you too.

Dr. Scott Steele

So Anna, let's talk a little bit about Cleveland Clinic's Colorectal Center for Pelvic Floor Disorders. What makes this multidisciplinary model here unique? And for someone who has maybe been bounced between different specialists or even different institutions for years without answers, what can we provide them here at the Cleveland Clinic? And how do the different specialties work together to ensure that it's the best treatment outcomes for patients?

Dr. Anna Spivak:

Thank you for asking this. This is certainly something we're very proud of here. We have an excellent group of physicians that are very like-minded, and we work together. And I've mentioned now a couple of times urology and urogynecology, that's our closest collaborators, but I also work very closely with pelvic pain specialists, with minimally invasive gynecologists who treat things like endometriosis, with Gastroenterology, with our pelvic floor physical therapists. We have psychologists on the pain side who work with patients with pelvic pain. We also have behavioral specialists on the gastroenterology side who work with patients relating their, what we call brain and gut connection. And talking to patients, whether it's nutrition, or eating, or whether it's just relating what's happening kind of with nervous system and the GI system. And we are very proud of this collaboration. And what makes us unique is that we work together, we collaborate, we have a multidisciplinary conference where we discuss complex cases, where we discuss the patients who need to see multiple specialists.

We also are fortunate to be in an institution where even outside of the specialties that I just mentioned, we have specialists and experts in pretty much every field where if we need to reach out to somebody from neurosurgery as we've done in a couple of cases, or we need to reach out to somebody from orthopaedics, we have the specialists, and we really can provide a truly multidisciplinary care and not just treat an isolated problem that maybe I'm an expert in one thing, but the body is a system of organs that works together. So we really collaborate to address everything at the same time, and really get to the root of the problem and address it.

Dr. Scott Steele:

That's fantastic. And so now it's time for our quick hitters, a chance to get to know you a little bit better. And since you've been on a couple of times before, we'll switch these up a little bit. First of all, what's your favorite dessert?

Dr. Anna Spivak:

Ooh, that's a hard one. I have a terrible sweet tooth, favorite dessert? Probably ice cream.

Dr. Scott Steele:

What is your favorite cartoon when you were a kid?

Dr. Anna Spivak:

Tom and Jerry.

Dr. Scott Steele:

Sun or snow?

Dr. Anna Spivak:

Oh, snow.

Dr. Scott Steele:

And then finally, for people who don't know, you're a little bit of a fashionista, so who's your favorite designer?

Dr. Anna Spivak:

Oh, I have to go with shoes. I'm going to plug in for Fluevog here. It's a phenomenal, very funky shoe company; I have multiple pairs.

Dr. Scott Steele:

Out of Seattle and Canada. So give us a little bit of a final take-home message. What's on the horizon for pelvic floor research that you're most excited about?

Dr. Anna Spivak:

I think we are really gaining a momentum with looking at the outcomes and understanding what surgeries work better. Unfortunately, prolapse is a disease where recurrences are common. There have been hundreds of surgeries described over the last century, and the reason there are so many surgeries have been described because none works. So we really, as a society, as a pelvic floor society and pelvic floor consortium part of American Society of Colorectal Surgeons, we are really gaining a momentum on learning to understand what works better. There is some new research that's on the forefront for fecal incontinence that involves cell therapies and that's very exciting. And I think that really multidisciplinary collaborations that really are coming together in the last 10 or so years is something that allows us to treat the patient as a whole.

Dr. Scott Steele:

That's fantastic. And so for more information on pelvic floor disorders and treatment here at the Cleveland Clinic, please visit clevelandclinic.org/pelvicfloor. That's clevelandclinic dot org slash pelvicfloor. And to speak with a specialist in the Colorectal Center for Pelvic Floor Disorders, please call 216.444.7000. That's 216.444.7000. Anna, thanks for joining us on Butts & Guts.

Dr. Anna Spivak:

Thank you so much for having me.

Dr. Scott Steele:

And to all our listeners, thanks for listening to Butts & Guts, and be sure to follow us on Apple Podcasts, Spotify, or wherever you listen to podcasts. For more episodes, you can also visit clevelandclinic.org/buttsandguts. That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.