Interstitial Cystitis & Endometriosis: Two Sides of the Same Coin?

[Dr. Jocelyn Fitzgerald]
We actually had this clinic today. The endometriosis center at Pitt was already established when I showed up being run by MIGS and they were seeing patients alongside pelvic floor PT at the same time plus or minus behavioral health, a psych piece. I am obviously very passionate about adding my urogyn expertise and bladder pain expertise and so I really wanted to be involved with the help of Nicole Donnellan, who you should probably have come on here because she's brilliant and awesome.
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Anyway, twice a month, we split the clinic in half. Dr. Donnellan's template is in the morning, my template is in the afternoon. In the morning, I have administrative time, but any patients that would benefit from me seeing them for a consultation for their bladder or for pelvic floor trigger point injections, I will go in and see that patient after she has seen them alongside pelvic floor physical therapy. They see the patient together and if the patient wants to get physical therapy that day without having to have multiple exams. We all have a discussion about the patient, they go across the hall to the physical therapy offices and they have physical therapy right then and there.

Sometimes I will even do pelvic floor trigger point injections, and then they'll go get PT immediately after their injection, which a really interesting paper came out last year showing that patients actually do have an improved response to PT if they have injections right beforehand.

[Dr. Mark Hoffman]
Before each visit?

[Dr. Jocelyn Fitzgerald]
Not each visit, but depending on the patient. If there's someone who just is not tolerating PT really well, I don't know, their pain is in a really specific area, we work with PT. PT often will see the patient first and then say, "I think this would be somebody that would respond really well to an injection before their visit," or, "If you could do injections first and then send them back to us instead of the other way around." I leave that to the PT's judgment. They're really good and they know when someone is not just going to cold turkey, be able to handle physical therapy day one.

[Dr. Mark Hoffman]
It's such an important part of it to be able to have PT, to have that relationship. I'm very lucky that our PTs are downstairs from where we are. I was part of bringing pelvic floor PT to UK because it was such a big deal at Michigan where I trained. People were using it, it wasn't like I brought it, but it was something that I was part of building it where it was because there was so much demand. They're right downstairs and the letters they write and we can communicate. Managing patients together is wonderful. It's amazing you've got them across the hall, though, and in the same visit.

[Dr. Jocelyn Fitzgerald]
Yes, same visit. It's awesome. Then in the middle of the day at lunch, we have a multidisciplinary meeting with behavioral health about patients that, in particular, need extra. It's almost like a tumor board where we are all part virtual, part in-person. We had it today and talked about some really challenging patients. That has been really great. There's still pieces that we're trying to add. We're trying to recruit a GI person. That's a whole other podcast, like how little training GI gets in gynecology and female pelvic medicine. We interviewed and are really trying to recruit someone who's interested in doing that from a GI perspective.

[Dr. Mark Hoffman]
GI, colorectal surgery, both?

[Dr. Jocelyn Fitzgerald]
Mostly GI. For really bad endo lesions maybe, but I really think on the medical side, you really need a good GI person who knows a lot about motility, understands how IBS and endometriosis interact, understand defecatory disorders and pelvic floor spasm, puborectalis spasm, dyssynergic defecation, that kind of thing. That's really helpful. They're not in the clinic, but we do have people from pain medicine, also some internal medicine people who are super close with PM&R. I have an emergency medicine doc who helps me make complex care plans for these patients, very similar to as if they were a sickle cell patient.

We have regular meetings where we talk about when they come to the ER with a flare, what are we giving them. Then our chronic pain specialist helps in those meetings as well, coming up with those plans. We have a lot of friends in the pot. We're still working on it but that's what I spend my time doing in that clinic, coordinating that care for these patients who have a lot of medical PTSD from just not being believed and going from doctor to doctor to doctor or you aren't talking to each other. My role is to talk to them, all for them. I write a lot of notes and messages and emails, but I think it helps.

[Dr. Mark Hoffman]
It's incredible. It's not an easy thing. Having people buy into what you're doing is, I think, my favorite part of this job, is getting people who are equally excited as you are trying to solve complicated problems. Being in a university seems to attract some of those. Some of us who like solving hard problems, doing hard puzzles, but finding other colleagues. I've got a colorectal surgery colleague who I do all my tough endo cases with and it's just my favorite days. In my fiber program, we build an IR doc, just like catching up. Imaging is a whole other thing. I don't know if you guys do much with that with radiology, but we've been very lucky too to do that.

Just having these partners solve these hard problems, but what can it do for patients to have that buy-in? I plea for docs out there with skills and ability to reach out and think about how you can contribute to women's health and these complex diseases that need more time, more energy, more effort outside of your own little wheelhouse. That's where I've had the most fun and had the most success, I think. Kudos to you and your group over there.

[Dr. Jocelyn Fitzgerald]
Oh, thank you. I really think those colorectal surgeons, all these specialists, I always tell them, I'm like, "This is an area, do you want to become famous in your field? Go back to your meetings with your colleagues and talk about how you manage this." There is nothing in the GI literature about how to manage IBS caused by endometriosis. That is not a thing in their IBS guidelines. It's probably like [chuckles] the majority of IBS in women is probably related to endo in some way or some huge piece of it and they don't even think about it. It doesn't even cross their mind.

When I tell them, their mind is blown. I'm like, "You could become really famous really fast in your field for basically writing guidelines that don't exist." The last thing I want to say is people who care, I don't want to undersell how important it has been to have administrators in our department who care deeply about women's health, people who have literally masters in healthcare administration. Most of our administrators are women, and they went into healthcare administration to help do women's health from that angle.

That is one of the most powerful things I've ever witnessed because we go into their office and say, "This is a population of patients who are suffering and they're falling between the cracks. We need you to help us set up pathways between psych, between the ER, between GI." They work on those things behind the scenes so that we can actually have resources and be profitable.

It's been shown in studies that you can generate a lot of new business for your healthcare system if you have these clinics set up. They have a lot of buy-in with us too and they phone in actually to our multidisciplinary meetings as administrators to see how they can support the clinic. That is the reason the clinic exists is because they are so devoted.