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BackTable / OBGYN / Podcast / Transcript #3
Podcast Transcript: Management of Female Stress Incontinence and Pelvic Organ Prolapse
with Dr. Amy Park and Dr. Jose Silva
In this cross-specialty episode of BackTable OBGYN, Dr. Amy Park chats with Dr. Jose Silva, a board certified urologist and co-host of BackTable Urology, about the workup, counseling, and management of urinary incontinence and pelvic organ prolapse. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Presentation of Pelvic Organ Prolapse versus Incontinence
(2) The Role of Cystoscopy Urodynamics in Incontinence
(3) Managing Incontinence Accompanied by Pelvic Organ Prolapse
(4) Utilizing Bulking Agents versus Sling Procedures
(5) Using Slings for Stress Incontinence
(6) Procedures to Manage Prolapse and Incontinence
(7) Patient Considerations: Age, Future Fertility, and Pregnancy
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[Jose Silva MD]
This is Dr. Jose Silva, your host this week. We are happy to have our guest Dr. Amy Park. Dr. Park obtained a bachelor's degree from Brown University then went on to study medicine at University of Rochester School of Medicine and Dentistry. She then completed her residency training in obstetrics and gynecology at the University of Pittsburgh, Magee-Womens Hospital in Pittsburgh, Pennsylvania, followed by her fellowship in female pelvic medicine and reconstructive pelvic surgery at Cleveland Clinic. Dr. Park is the section head of female pelvic medicine and reconstructive surgery. Welcome to BackTable, Amy.
[Amy Park MD]
Thank you, Jose.
[Jose Silva MD]
How's the world in Cleveland?
[Amy Park MD]
Actually, it's pretty good. I'm pretty happy. It's like you can't beat summers in Cleveland, but you can beat the winters. It's pretty cold here, but the summers are awesome.
[Jose Silva MD]
No, here during the day it's like 120 degrees, maybe I'm making it up, but very, very hot. Then around six or seven storms every day. Right now it's pouring outside. It is just crazy weather here during the summer. Amy, so you're doing female reconstruction and pelvic medicine at Cleveland Clinic. Let's talk about incontinence and a little bit about prolapse.
[Amy Park MD]
Sure.
[Jose Silva MD]
How about that?
[Amy Park MD]
Perfect.
(1) Presentation of Pelvic Organ Prolapse versus Incontinence
[Jose Silva MD]
I do some incontinence in the office. I don't do prolapse, but patients call the office saying, "Ah, my PCP tells me that my bladder has fallen." At first, I didn't give them appointments because I don't do the fallen bladder or prolapse, but most of the time it's just incontinence. I started seeing them all the time and most of them it’s just incontinence, not prolapse. What symptoms do patients with an actual prolapse present with?
[Amy Park MD]
Well, typically patients with prolapse present with sensation of vaginal bulge, pelvic pressure, something coming out of the vagina, splinting, which is pushing on the vagina in order to urinate or defecate completely. Sometimes they can have painful sex.
[Jose Silva MD]
Exactly. Most of the time they're just coming - at least in my practice - definitely they come for incontinence. Sometimes they do feel the bulge coming out. Are you doing pelvic exams on that first visit for everyone?
[Amy Park MD]
Yes, I think that the most important part is the history obviously. That's where I can really glean whether or not people have stress incontinence, urge continence, symptomatic prolapse. This is a quality-of-life issue. I don't really need to treat it if it's not bothersome to the patient. I do a pelvic exam on the first visit for everybody unless they're an adolescent, in which case I'll just go by symptoms or image with MRI or something like that. Otherwise, I will assess the neurologic function in the S2 through 4 distribution.
They're really like ankle reflexes. If they're absent, it's no cause for worry, but if they're present, it's reassuring that the reflex arc is intact. It's mostly useful if it's asymmetric, which indicates nerve damage on the side of the absent reflex. I also perform a pelvic exam using the pelvic organ prolapse quantification system or POP-Q in order to assess the extent of prolapse.
The other grading system is Baden–Walker system or the halfway system. That's like if the leading edge of prolapse comes halfway down the vagina or to the hymen or halfway or all the way out. The bottom line is when the leading edge of prolapse is at the hymen, that's usually the threshold at which people start feeling the symptoms.
Then I also perform a speculum exam to assess the cervix, uterus, adnexa, as well as a rectal exam. I also have patients perform the cough stress test. Also part of my evaluation, I check a urine dip just to make sure they don't have a urinary tract infection and a post-void residual volume via bladder scan. If it's elevated I will perform a straight cath, but most of the time I just do an ultrasound for patient comfort sake.
[Jose Silva MD]
Okay. You mentioned the ankle reflex. Let's say if it's abnormal on one side, does it push you directly to some sort of treatment, or what happens next?
[Amy Park MD]
Usually, if they have an absent reflex on one side, usually they've had a significant event like pelvic surgery or radiation or some sort of traumatic birth injury, and they have something that goes along with it. As long as they don't have any problems with the paresthesias, it usually doesn't really change my management that much, but I just note it so I can document it.
Then also in case something happens after surgery, you always want to demonstrate that it pre-existed prior to the surgery. Actually, this is a tangent, but when I was a fellow we did a study, it was a prospective cohort assessed patients for neurologic injury after gynecologic surgery, and a lot of people had preexisting neurologic conditions or numbness or weakness or some sort of abnormalities. I think it's important to document.
[Jose Silva MD]
Yes, so they don't blame you afterwards, especially after complaining of pelvic pain afterwards, after any type of surgery.
[Amy Park MD]
Exactly.
(2) The Role of Cystoscopy Urodynamics in Incontinence
[Jose Silva MD]
In terms of cystoscopy urodynamics for incontinence, what are you looking for when you do a cystoscopy? Are you doing cystoscopy on everyone, or not really?
[Amy Park MD]
Well, in terms of preoperative procedures, cystoscopy, or urodynamics, my short answer is that I'm selective. When I first started practicing I did urodynamic cystos for essentially everyone with overactive bladder or urge incontinence, but now I just empirically start OAB meds for urinary urgency symptoms which correlates with what most people do, unless they have a UTI or elevated post-void residual. I'll treat the UTI first or just work up the elevated post-void residual with other things.
I usually reserve urodynamics for those patients who've had prior anti-incontinence procedures like Burch colposuspension, or a sling, or they have underlying neurologic conditions like stroke or multiple sclerosis, they've failed prior OAB meds, or the history is not quite clear whether or not they have stress or urge incontinence. Say, they have continuous leakage of urine or their history just doesn't go with either of them.
Then I also routinely perform urodynamics preoperatively for those patients who have not demonstrated stress incontinence on their pelvic exam. There was a big NIH-funded trial called the value trial for those patients who have stress incontinence or stress-predominant mixed urinary incontinence. If you have a positive cost stress test, normal post-void residual less than 150cc, and a normal urine dip, there's no added value or benefit or change in outcomes with complex channel urodynamics.
Then for cystoscopy, I'll perform that if a patient has a history of a prior anti-incontinence procedure, like I said mesh sling or Burch or MMK colposuspension, or if the patient has failed OAB meds and is going for Botox, but then I'll just perform the bladder and urethral cystoscopic survey at the time of Botox. I used to do urodynamics and cystoscopy and then have them come back for the Botox, but the vast majority of the time it's normal at the time of Botox. So I just save them that extra cysto.
[Jose Silva MD]
Have you had a patient where they go in and have a small mass or something?
[Amy Park MD]
I have, very occasionally, but it's so rare. I think I just see a different patient population, which is I think more low risk than the typical urologists. As you know, most of the time those present with a little bit of hematuria or at least something, but very occasionally I've seen some early-stage transitional cell or urothelial cancers, but it's pretty rare.
[Jose Silva MD]
Is the patient more satisfied if you go straight into cysto with Botox rather than going cysto first, and then another cysto with Botox? Have you seen a difference?
[Amy Park MD]
No, I haven't asked them. I just assume it's more comfortable.
[Jose Silva MD]
Because I always think about it. I haven't done it, but I always think about it, "Hey, why do this twice?" Like you said, most of the time there's really nothing, and you end up going to do the same thing again.
[Amy Park MD]
Yes. I rarely find something. Sometimes I just find that they have a lot of trabeculations, which is what I would have expected anyway, but I don't usually find anything bad like a mass or cancer. Then I will do one for sure if the patient has had a prior mesh sling, because I have seen occasional mesh erosions into the bladder, but otherwise, I don't do it for just refractory urge, and they failed anticholinergics or something like that.
(3) Managing Incontinence Accompanied by Pelvic Organ Prolapse
[Jose Silva MD]
For patients that have stress, or any type of incontinence, and when you do the pelvic exam, they don't have symptoms of prolapse, but there's a little bit of prolapse there, let's say POP 0 or -1, that is not going outside the vaginal area. When do you decide to treat the prolapse as well when you're treating the incontinence?
[Amy Park MD]
That's a really good question. There was a study looking at this ancillary data with some of the NIH-funded studies on prolapse and incontinence. Basically for those patients who have stage 2 prolapse, which is right around the hymen, and some of them are symptomatic and some of them aren’t, there's not really a big progression in the prolapse. My take is there are some sequelae to treating prolapse surgically. It's rare, but I don't want to risk dyspareunia number one. Number two, you really can't improve on no symptoms. I tend to not treat asymptomatic prolapse unless they for some reason have something else that's pushing me. Like they have abnormal uterine bleeding, and I might as well do a hysterectomy at the same time, and then I'll do a prolapse repair. Or if they have some incomplete bladder emptying, and it's like prolapse related voiding dysfunction. Otherwise I don't treat asymptomatic prolapse.
[Jose Silva MD]
Sometimes I see sling patients that have seen other urologists and they already have the workup, and they scale it directly to me for surgery. When I'm there, I see a little bit of prolapse. I don't know if it is the prolapse or-- I don't do the sling. For now, I haven't had any problems, but I always have the doubt whether they needed more treatment. At least, for now, it hasn't happened but I’m always curious when you actually treat the prolapse.
[Amy Park MD]
Yes. I think that that was definitely more of a question before, that I had. You see it coming down a little bit, and you're like, "Oh, should I just deal with it at the time of surgery?" Honestly, the slings work better in the setting of urethra hypermobility. If you really push it back, they don't actually work as well because the mechanism of the sling is really it backs up against, which the urethra can compress with a hypermobility. I actually think the sling may work a little bit better if they have a little bit of prolapse, but you don't want it to be obstructive. That's the thing that people worry about, is when it gets to that point where you wonder, "If it comes out some more, is it going to be a problem for their emptying?" That's when I think you just have to judge and see. But a lot of people with advanced prolapse still are able to empty completely.
[Jose Silva MD]
Okay. In terms of pelvic floor exercises, let's say a patient with stress incontinence, but also symptomatic prolapse. Do pelvic floor exercises do anything or do you really just need to treat the prolapse and the incontinence?
[Amy Park MD]
I think pelvic floor PT is very good at addressing urge incontinence, levator spasm, and pelvic pain. I think it's imperative to have a partnership with pelvic floor physical therapists. The caveat to pelvic floor PT for addressing urge is that patients have to keep up with the exercises. The physical therapists are also very good at addressing the underlying causes for levator spasm and pelvic pain, like underlying back pain and hip pain. It's less good at effectively treating SUI and prolapse.
There's a couple different techniques that the PTs will teach patients for stress incontinence, like something called the knack, where the patients can kegel, cross their legs and turn their bodies to the side, and it helps pull up their pelvic floor. It doesn't completely stop the leakage, but it decreases the amount of leakage that they experience with coughing, sneezing, and Valsalva.
Then for prolapse, I counsel patients that the PT isn't going to magically retract the prolapse back up, but it will help in most of those cases where the leading edge of prolapse is right at the hymenal threshold, which is where patients become symptomatic. So they don't really feel it as much anymore. I've also encountered several patients that have strengthened their pelvic floor through performing core-centric exercises, like karate or Pilates or barre, and have experienced treatment. Weight loss also improves pelvic floor disorders.
(4) Utilizing Bulking Agents versus Sling Procedures
[Jose Silva MD]
Amy, in terms of the SUI stress incontinence for sling procedures, when are you doing a sling procedure versus a bulking agent?
[Amy Park MD]
I think the bulking agents are good for patients who aren't really good candidates for sling. Cancer patients, post-radiation patients, patients who've had healing issues like mesh erosions from a prior sling, women who desire future fertility or have a fixed urethra, or patients who are too sick to go to the OR, I think it's a good medium-term option.
Basically, the data demonstrates from Europe, when they compare the Bulkamid urethral injections to the sling, pretty good results up to seven years, and they were comparable. The sling actually has longer-term data up to 17 years. I always counsel patients that if they want a more permanent solution to the incontinence, that the sling would be a better option. But I have some patients who have too much going on. They're busy, they like the idea of doing an office procedure or something quick in the surgery center. That's my practice, but I'm curious to hear what you've been doing because I think with urology and urogynecology, sometimes we have a little bit different patient populations coming in.
[Jose Silva MD]
I think more or less the same thing that you just said. I definitely ask the patient if they want to continue being active because I do TVTs, I do the Advantage Fit, and I tell them that it's going to be three to four weeks of really nothing, no exercise. I know that might be challenging, but if they want something that they can go back to their regular life faster, then the bulking agent, I think you said the Bulkamid, I think it's a better option. Of course, if it doesn't work. You can bulk it again or put a sling. That's how I talk to the patient. Not sure if I'm doing the right thing.
[Amy Park MD]
No, it's totally true. The downtime is a huge issue for patients. Previously I was always hesitant to recommend urethral bulking agents because I just didn't feel like they worked very well. A lot of times I would talk the patients out of it, even though I did mention it as an option in my standard surgical counseling, but the Bulkamid is so much easier to inject and with longer lasting results. So I feel better about counseling because I think it's a more legitimate option.
[Jose Silva MD]
I didn't do any bulking agents before. I just started with the Bulkamid. Definitely, seven years of good results is better, I'm not going to be doing this every six months. That's why I did more slings. But now with Bulkamid maybe, I think it's taking away from the patients that did slings.
[Amy Park MD]
I still do a lot of slings, but I'm definitely doing more bulking agents than I ever did just because it's also easier to counsel patients about the fact that it's a hydrogel, it's 97% water, has 70% to 80% improvement for up to seven years. The prior ones that I used, I used Contigen, but having to do the skin testing for the bovine collagen reaction, allergic reaction, was a barrier.
I never found Coaptite to be that effective. When I would go back for repeat injections or placing a sling, the calcium hydroxyapatite material would often migrate or extrude. I think the Bulkamid probably does migrate a little bit. All of them do. It's just a lot easier to use and the patients have pretty good results immediately.
[Jose Silva MD]
Have you had to do a sling after Bulkamid?
[Amy Park MD]
I did do one. I did see a little bit of migration of the material into the trigone.
[Jose Silva MD]
Into the trigone. Did the patient have any overactive symptoms, or disorder, or anything?
[Amy Park MD]
No. We biopsied it. It was just inflammation.
[Jose Silva MD]
So no symptoms from that part. It was just that it didn't work that much.
[Amy Park MD]
Yes.
[Jose Silva MD]
In terms of the surgery, the technique, did you see any difference, or was it more challenging?
[Amy Park MD]
No, but I have done- not with Bulkamid, but I have done a sling after Coaptite, and I did one on somebody who had I think Macroplastique, and they do get sometimes like this- it can either be gelatinous or a pasty material underneath the urethra where you can tell where they injected along the mid urethra and up to the bladder neck. The Bulkamid, I didn't see that. It had migrated more along a different tissue plane. I think now that we're using more Bulkamid, I'm curious, when I go back, what's going to happen.
[Jose Silva MD]
Definitely. The advantage of doing it in the office. I'm still doing it with sedation in the OR. Definitely, the idea is to move towards the office. It is an advantage just for that. I think that's the benefit, that you can do it in the office and be better.
[Amy Park MD]
One of my partners gave me a tip of doing periurethral injections for the urethra bulking in the office. You just take like a 22 or 25-gauge needle, and then you just inject some lidocaine along the urethra. That really helps. Then for the Botox, I usually give both pyridium and indwelling lidocaine for 20 to 30 minutes. Those also help.
[Jose Silva MD]
You also give pyridium, does this affect visualization of the bladder?
[Amy Park MD]
No, you give it to them right at the time they have a negative urine dip. It's only like 20 or 30 minutes that they're in the office. It does help. It's definitely a very good analgesic. I throw everything at them. I'll even give them a dose of Ativan, like .5, and an oxycodone to bring to the office just to keep them out of the ASC every six months. Some patients, they just want to have it in the ASC. Most of the time I can do Botox in the office for sure.
[Jose Silva MD]
Do you use rigid or flexible in the office?
[Amy Park MD]
Rigid. I have all women. I know for you guys it's different.
[Jose Silva MD]
Yes, I use flexible for both women and men. Definitely, I'm going to start using the Ativan. I don't give them anything, just the lidocaine. A friend of mine told me about the Bulkamid. He essentially used the Lido gel first and then uses the periurethral block. He has been having great results.
[Amy Park MD]
For sure. I think all these little tricks are what help you achieve the patient satisfaction and analgesia in the office setting. It's just a totally different situation.
(5) Using Slings for Stress Incontinence
[Jose Silva MD]
Exactly. Right now I've been doing the ASC. We use propofol and I use the periurethral block and they come out without any pain or anything. I think I had one that had dysuria after the procedure, but after a couple of days, it was fine. Amy, so in terms of stress incontinence, what sling are you using?
[Amy Park MD]
I used to use the Boston Scientific Advantage Fit, like you mentioned. Now I use the Gynecare TVT Exact for the retropubic approach. For the TOT, I usually use the Boston Scientific Obtryx. All the data support the bottom-up approach for the retropubic approach, and the outside-in approach in terms of higher efficacy and less complications outside end for the transobturator approach. I think the most important thing is to get good at the sling that you choose because they're all slightly different in terms of handling and tensioning.
[Jose Silva MD]
How do you decide whether TVT or TOT?
[Amy Park MD]
I trained mostly performing TOTs with the rationale that there's less bladder injuries and voiding dysfunction, unless the patient shows evidence of ISD. When I became an attending, my group was performing mostly retropubic sling so I switched over at that time. I've definitely found that the paraurethral bands from the TOT mesh and the fornices can cause some dyspareunia, and it's easier to get a mesh erosion there.
There's been enough studies and meta-analyses since I graduated fellowship in 2009 that have accrued enough power in terms of enough number of patients that show that the retro pubic slings are more effective in addressing SUI compared to the transobturator approach. The other side of the coin is, although they are more effective, they do have higher rates of voiding dysfunction and bladder injuries like I mentioned.
Then I don't really perform the mini slings. When I first came out of practice, I had to remove a bunch of the mini slings due to pain and dyspareunia from the pledgets into the obturator internus and just lack of efficacy in addressing the stress incontinence. There's a recent New England Journal of Medicine randomized trial. It was a non-inferiority trial comparing slings to mini slings, to either the TOT or TVT, like a full-length sling. This trial showed non-inferiority, but higher dyspareunia rates, 5% versus 12%, which definitely tracks with my experience. I'd rather put in a sling that works without causing issues.
[Jose Silva MD]
I guess now with the bulking agent, there's no reason for the mini sling. You can try the bulking agent, if not just put in a regular sling.
[Amy Park MD]
I think that we had benefited from the data from Europe and the rest of the world, where a lot of mesh slings were actually banned or taken off the market. I think it accelerated the widespread use of Bulkamid. They have been very hot on the Bulkamid urethral injections. Now that it's rolled out in the US, I think we're seeing a lot of enthusiasm, just like you and I are pretty excited about it, I think a lot of other people are. The next frontier I think in terms of the bulking agents is the stem cell, the autologous injections. One of my colleagues at the clinic, Howard Goldman is the PI, one of the PIs in the study, and I'm curious to see how that works.
[Jose Silva MD]
That will be awesome. I think a lot of research is going into that field. For example, erectile dysfunction, there is a lot of promising data using that. We'll have to see what stem cells are going to do in the urinary tract. Amy, in terms of bulking agent or Bulkamid, what do you tell the patient what to expect after the procedure? What are the positive side effects from bulking agents?
[Amy Park MD]
I counsel the patients that it's 70-80% improvement for up to seven years. Usually, people do well. When I sign the consent form, I’m like “there's bleeding, infection, urinary tract infection, and then some voiding dysfunction can also occur.” When I first started doing Bulkamid, I had a couple of patients that couldn't void in the recovery room of the ASC. So they had to get straight cathed, and the hope was to pass the catheter so it would create a tract and the patient would be able to pee. It's like a small catheter. I can't remember what it was, like…
[Jose Silva MD]
12 FR.
[Amy Park MD]
12 FR. Then one of the patients still couldn't urinate. Then I had to send her home with a Foley. Then she came back in, she passed her void trial, and then she came in retention again, like 800 CCs or something. Then I started taking the voiding dysfunction a little bit more seriously because if you talk to the company, they're like, "That never happens."
[Jose Silva MD]
Exactly.
[Amy Park MD]
Has that happened to you?
[Jose Silva MD]
No. But it was with a sling. It was recently. This patient- when I started the procedure, I put in the Foley catheter, and she already had 900 in the bladder. Afterward, I check out my notes. She never had elevated PVRs prior to surgery or anything in the office. So she had retention. I wasn't sure, because of that episode, that when I started the procedure that she already had 900. I wasn't sure. Still, I took her to the OR, and I cut the sling on one side. Then she voided. She's doing fine. I don't know how much of it was from the anesthesia for the procedure. I don't know.
[Amy Park MD]
That's a interesting question. I think there are data showing that when you perform a sling lysis, if you do it in the midline, or you do it on the side so it's more of a J configuration, you still get that mechanism of the backstop.
[Jose Silva MD]
I do it on the side.
[Amy Park MD]
I think that the side actually makes sense. I haven't tried that method. Have you noticed that you achieve the continence and then the voiding?
[Jose Silva MD]
Yes. I haven't had to do it often. The ones that I have done, they're fully continent.
[Amy Park MD]
Oh, that's great.
[Jose Silva MD]
They're happy. Maybe the mini sling works somehow. I don't know. These have been TVTs, but if you're cutting one side essentially, you're just leaving something there sometimes. Who knows what exactly is going on in some patients, just like that patient that had 800 of PVR. Maybe it was the anesthesia, who knows?
[Amy Park MD]
Yes, or just they got overdistended
[Jose Silva MD]
Let the bladder rest for a while, exactly. Because of that patient, I leave my slings with one night of a catheter. She passed the voiding trial. We always fill up the bladder and have her urinate, so she was voiding. She wasn't in retention, I don't know, from the sling. I don't know. Still, I took her to the OR just in case. I didn't want to do a lysis a month after so I just took her a couple of days afterward. She passed her initial voiding trial, and then she developed retention overnight.
[Amy Park MD]
It's always funny when they pass the initial voiding trial, and then they fail again, but it happens. It's rare, luckily. You don't have to wait for longer, or if they can't urinate at all, I just cut it.
[Jose Silva MD]
It's probably a mess afterward, and you just tell them, "Hey, we need to cut it." They're not pleased because it’s another time to the OR. It is what it is.
[Amy Park MD]
Exactly.
(6) Procedures to Manage Prolapse and Incontinence
[Jose Silva MD]
So for prolapse and incontinence, are you doing combined procedures or do you prefer to treat one first and then see how that person does?
[Amy Park MD]
If the patient doesn't desire surgical management, they can be fitted with an incontinence dish or ring with support and knob that reduces the prolapse and addresses the incontinence as well, by providing support to the bladder neck.
If the patient desires surgical management and has preoperative stress incontinence, then I counsel them that I can address both conditions at the same time. Because some patients may be wary or hesitant to have mesh placed, then I engage in shared decision making and give them the option of preoperative urodynamics and concomitant sling at the time of prolapse repair, or proceed with a staged approach forgo the preoperative urodynamics with interval sling placement if they become more bothered after prolapse repair. Occasionally, patients will not demonstrate stress inconvenience on preoperative dynamics. I will counsel them on performing a concomitant sling anyway since the data are supportive of that approach in terms of patient satisfaction and also because as we all know, urodynamics are an imperfect test. If the patient does not have preoperative SUI, then they still have a fairly high risk of developing de novo SUI postoperatively in the range of 40% to 50%.
I offer patients the same choices in terms of preop urodynamics and concomitant sling if it's positive for stress incontinence or the staged interval sling approach. Even though prolapse repair does not address incontinence per se, studies have shown that when you address anterior wall prolapse, urinary urgency does improve. Prolapse repair definitely helps with prolapse-related voiding dysfunction. I think the real danger area is for advanced prolapse that has caused long-standing bladder outlet obstruction, detrusor hypertrophy and underactivity, and then the patient has SUI. I would tread cautiously in that patient and possibly consider a bulking agent or a very loose sling.
[Jose Silva MD]
Exactly. That's what I was going to mention, at least the very loose sling because the first time that I had to cut a sling was a combined procedure. The GYN did the AP repair and I did the sling. I left it like I always do. And that patient, they were in retention and then I was talking to a friend of mine, like "Yeah, you need to leave it much looser because when they do, they close the AP repair, the defect, it tends to tighten it up." When you say looser, how do you create that? Do you leave something between the urethra and the sling to get that amount of looseness?
[Amy Park MD]
Yes, I use curved mayos underneath the mid urethra, and then I just make sure that I can just easily pass it between the mesh and the urethra. There was a Canadian RCT looking at mesh sling tensioning techniques and either using an instrument. I can't remember exactly what they used. It was either a curved mayos, or maybe it was a right angle or something. Then the other arm was using a Babcock. I think the Babcock had a higher mesh erosion rates, which makes sense because it’s a little bit of a knuckle of the sling that you leave out. I just have always used the mayo scissors underneath and then just making sure that it can pass easily.
[Jose Silva MD]
I use essentially a female urethra dilator. I leave a 10 FR, very small. I just put it there. I used to have the right angle, but just trying to keep it systematic and doing the same thing over and being able to make sure there’s space. So I changed to the 10 FR. What type of prolapse procedures do you do?
[Amy Park MD]
I do the vaginal approach as well as the laparoscopic approach. My go-to is the vaginal hysterectomy, bilateral salpingectomy, uterosacral ligament suspension, anterior-posterior repair for those women who still have the uterus. For select patients, you can talk about a hysteropexy with uterine conservation if they don't have a history of abnormal Paps or cervical elongation or enlarged uterus with fibroids. I'll perform the vaginal uterosacral ligament suspension intraperitoneally. Sometimes, occasionally I will perform a sacrospinous ligament hysteropexy.
The advantage to the uterosacral ligament approach is that it preserves a natural access of the vagina, whereas the sacrospinous ligament fixation stays extraperitoneal, it deviates the vaginal access laterally and can cause buttock pain for up to six weeks. For post-hysterectomy patients, I'll offer either sacrospinous ligament fixation or laparoscopic sacrocolpopexy. For the high posterior prolapse, I actually think the sacrospinous ligament fixation works great.
My approach is to take a diamond from the top and then just measure with Allis’s, make sure that it goes up to the sacrospinous ligament, and then shorten the vagina to where it doesn't just right on the sacrospinous ligament because I think it's the length that's very important there. For the predominant anterior apical prolapse, I prefer laparoscopic sacrocolpopexy.
That being said, I'll steer the patients towards the vaginal approach if they've had a lot of abdominal surgeries, they have a large hernia repair with mesh, history of small bowel obstruction, contraindications to steep trendelenburg like a severe pulmonary disease, contraindications to mesh like wound healing issues or significant comorbidities that preclude longer OR times associated with sacrocolpopexy.
I usually counsel patients that prolapse repairs are like any other reconstructive surgery in the body like an ACL tear or facelift or knee, hip replacements. The natural history of the disease is that the connective tissue will weaken. Therefore, I usually reserve laparoscopic sacrocolpopexy for those patients who are post-hysterectomy with anterior apical prolapse who have had a recurrence or want the most durable repair. I do perform primary sacrocolpopexy with concomitant hysterectomy or sacrohysteropexy in those patients who are young, like less than 40, who desire the most durable repair. But that's not my usual go-to.
(7) Patient Considerations: Age, Future Fertility, and Pregnancy
[Jose Silva MD]
You mentioned the less than 40 years old, but older patients, older population, do you prefer vaginal? Is it something that you take into consideration, the age of the patient, between the vaginal and abdominal approach?
[Amy Park MD]
Yes. There's been studies looking at failure rates after vaginal versus the laparoscopic sacrocolpopexy. For the vaginal approach, risk factors for failure are: age less than 60, stage three or four prolapse, and history of prior prolapse repairs. I did at the beginning of my career start with doing a lot of primary sacrocolpopexy. I will say that over the course of my time as an attending, the field was shaped by the mesh litigation, and patients became very hesitant about the placement of mesh.
Now that the transvaginal mesh kits for prolapse are off the market, I think it's a lot easier to counsel patients about it because sacrocolpopexy has never been even mentioned during any of these warnings or targeted in any lawsuits or anything like that in terms of large multi-district litigation. I just saw that patients evolved from being pretty receptive to sacrocolpopexy to not wanting to even have a sling.
So I have a whole counseling about the use of transvaginal mesh for slings, the use of mesh for sacrocolpopexy. I think for those who are younger and want to be one and done, I think the sacrocolpopexy makes more sense. I tell people it's just like a hernia repair, reinforces that area of weakness, whereas the vaginal repairs just uses stitches. I often give that orthopedic analogy of a knee replacement versus just repairing your ACL. Patients, they understand. I think they're very savvy consumers of health information for the most part.
[Jose Silva MD]
What about patients that are not sexually active? Does that change anything in your management?
[Amy Park MD]
You know what? What if they are not sexually active, I did not mention, there's a procedure called the colpocleisis, which if they have a uterus, and they don't have any history of abnormal paps or post-menopausal bleeding, it just leaves them with a shortened vagina in terms of the LeFort colpocleisis. Then if they're post-hysterectomy, we can do total colpocleisis, which also leaves them with a shortened vagina. Those patients have very high cure rates and it's a shorter procedure with very high patient satisfaction. I always document though, about potential regret over not being able to be sexually active in the future. For the properly selected patient, I think it's a great procedure.
[Jose Silva MD]
They need to be true that they're not sexually active, right?
[Amy Park MD]
Right. Also, patients may not be sexually active, but they want that option to engage in that in the future or just the idea of it. I think it's definitely a personal choice. Many women don't mind not being sexually active by the time they're older. For them, I think they'll take you up on that offer. A lot of women just want a different kind of procedure. That's also fine.
[Jose Silva MD]
Amy, in terms of, I didn't ask you this, for stress incontinence, do you vary, or do you offer different types of treatments based on age? For example, if a 20-year-old person that already had three pregnancies, has stress incontinence, are you offering the same or are you doing something different?
[Amy Park MD]
In those patients, who are very young, and who want future fertility, I definitely would steer them towards an incontinence pessary or the Bulkamid urethral bulking injections. If they're done with childbearing, then I don't have a problem with putting in a sling. I did have a recent patient who presented in her late 20s, and she had a sling placed and now she's pregnant. I think it made sense looking at her chart and talking to the patient why she elected to proceed with a sling, even though at the time she was nulliparous because she said it was just so bothersome and really harmful to her self-esteem and her quality of life. Actually, there's a really good American Urogynecologic Society clinical guideline on patients who have been treated with pelvic floor disorders like a sling, and then recommendations for mode of delivery, like should they have a C-section. Basically, there's not enough data to recommend one approach or the other. I did counsel her that she's a high risk of developing recurrent stress incontinence if she went to vaginal delivery or prolapse in the future, if she had vaginal delivery. Even just pregnancy itself can do that to you. I don't think that there's enough data right now to support doing one or the other. She also wanted to have three or four children. The risk of cesareans and abnormal placentation in future pregnancies is definitely something to keep in mind. That's something that we'll definitely see.
For the older patients, I think it really just depends also. Some patients are 45, and they don't want to have a sling. I think it just depends. Then it just depends on their comorbidities and whether or not they're able to go to the operating room, like I mentioned earlier.
[Jose Silva MD]
For that patient that you mentioned that had a sling, she was 27, she has another pregnancy. What do you counsel? Do you counsel that you need to take out the sling, or just let it be and see what happens?
[Amy Park MD]
Yes, just let it be and see what happens. A lot of times, there's like a bunch of case series of a couple patients who got pregnant after sling placement. A lot of them do fine. Some of them do go to urinary retention and have to undergo sling lysis. For the most part, they usually do pretty well.
[Jose Silva MD]
For a patient that, let's say a young patient also in their 20s, they get a sling. Do you counsel them that in the future they might have a high risk of needing another sling 20 years from now, or what do you tell them?
[Amy Park MD]
Oh, yes. Basically like a lead time bias. We deal with this with tubal allegations, just a lot of women years. If you tie someone's tubes when they're 25, you basically have another 20 years of fertility to guard against whereas if you're 45 and do tubal ligation, you don't have very long to go until menopause. The same thing with treating pelvic floor disorders. If you treat them early, you treat them in their 20s, they have another 50 years of living. They have a much higher chance for it to fail. It's just time.
I try to underpromise and over-deliver, and manage expectations. Then patients, they never really push back on it. They understand. Especially when I give that orthopedic surgery analogy, many of them have had orthopedic injury, like shoulder problems or knee replacements or hip surgery or whatever. They understand that, too. I think in the past people did promise that it would hopefully cure their prolapse. I just have a different view of it. I'm like, "It's going to come back. This is reconstructive surgery. No reconstructive surgery in the body lasts forever." Patients are like, "Okay, that's fair."
[Jose Silva MD]
I'm going to steal that one from you. It's reconstructive surgery. Doesn't last forever.
[Amy Park MD]
It doesn't last forever. Our group at the Cleveland Clinic has been in existence for over 25 years. Mark Walters is one of the founding fathers of urogynecology. He was here since the mid-'90s, maybe even the early '90s. So we're definitely seeing recurrences. They had very good surgeries that lasted 20 years, the Burch colposuspension, the slings in the early 2000s. It does come back. I think counseling patients in a realistic manner is also important because then they don't feel like they ruined something or you did something wrong. It can happen.
[Jose Silva MD]
Exactly. Amy, any last words to our listeners?
[Amy Park MD]
No. Thank you so much. I really appreciate being able to come on the podcast and to talk about one of my favorite topics.
[Jose Silva MD]
No, definitely the pleasure is mine. Thanks for being here and giving your insights on this topic as the expert that you are. Thank you.
Podcast Contributors
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2022, November 14). Ep. 3 – Management of Female Stress Incontinence and Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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