Treatment of incontinence and pelvic prolapse

September 17, 2006

OBGYN.net Conference CoverageFrom the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003

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Barbara Nesbitt: “Hi, I’m Barbara Nesbitt. I’m the editor of OBGYN.net and I’m at AUGS. We’re here for the American Urogynecological Society conference. I have the pleasure of being with Dr. David Robinson and Dr. Dennis Miller, who are members of the OBGYN.net Urogynecology Advisory Board.

I’m going to ask them a couple of questions, and then we’re going be educated on incontinence and prolapse, and why it’s important to get good and proper care.”

David B. Robinson, MD: “Barbara, I’m in a ten-person OBGYN group in Topeka, Kansas and my practice is limited to treatment of incontinence and pelvic organ prolapse.”

Dennis Miller, MD: “I’m Dennis Miller, not the comedian, and I’m in a practice in Milwaukee, Wisconsin called, Milwaukee Urogynecology. We focus on the treatment of incontinence and prolapse in women exclusively.”

Barbara Nesbitt: “What is incontinence and why is it important to seek treatment for it?”

Dennis Miller, MD: “I think one of the mistakes, or myths, that people have is that it has to be of a very significant severity before they seek treatment, and it really is a patient driven decision. You can seek treatment for incontinence or prolapse any time that you find it bothering you, changing your lifestyle, or embarrassing you.”

Barbara Nesbitt: “What would some of those symptoms be; coughing, leakage?”

Dennis Miller, MD: “Just in general, incontinence is defined as the accidental and embarrassing loss of urine. But it also can include other kinds of, what we call, voiding problems, abnormal frequency of urination. One general definition is urinating more than every two hours, or getting up more than twice at night, or an abnormal urgency of urination as well.”

Barbara Nesbitt: “A lot of women think that it’s something that happens as they age. Is it more from childbearing, what would the cause be? At what age do you find it hits?”

Dennis Miller, MD: “It’s interesting that really it’s relatively evenly distributed across all the decades of an adult’s life. We’re more apt to see young, active, vigorous women because they are intolerant of living with these symptoms.

I would have to say that the most common age that patients will present at our office is between 45 and 55. But we see women as young as 20 and we see women as old as 100.”

Barbara Nesbitt: “Now, I think Dr. Robinson, you said that you would explain prolapse, and there is a difference.” 

David B. Robinson, MD: “Well Barbara, they are different. They are often associated together. One of the things that happened in the patient population is often to assume that because they are incontinent of urine that their “bladder” needs to be tied up. And really that has become a lay-term that is inaccurate. People may have prolapse of their pelvic organs without being incontinent at all, or vice versa, they may be very incontinent and have absolutely no prolapse. So they are different problems.

What has become known as Pelvic Organ Prolapse refers to loss of support of the bladder, the uterus, the rectum and all of which may bulge into the vagina and downward. I think it’s critical that patients realize that just because they have some degree of loss of support of those organs does not mean that they need any treatment at all. And I think physicians need to realize that too. You need to treat these patients based on their symptoms, and whether those symptoms are bothersome to them, rather than the mere presence of some degree of prolapse.

So if a patient feels a considerable pelvic pressure or back pain and a sensation of her organs falling out, or if in fact she is aware of protrusion of organs from her vagina and they rub on clothing, or they bleed, or they become uncomfortable; those patients are going to seek treatment and need to be diagnosed and appraised of their options, and then choose a form of treatment.

So I think it’s important to not skip over the diagnostic steps. Come up with a firm diagnosis before leaping to treatment. Often in the past I think, particularly with incontinence, there’s been a very quick leap to treatment with bypassing of the diagnostic stage. We know there are at least 13 different reasons that women will leak urine. Two of those account for most of the diagnoses but coming up with a firm diagnosis is still critical to getting good treatment.”

Barbara Nesbitt: “I have heard many doctors say to me, when I’ve gone to different conferences, that this is probably one of the larger areas that women are embarrassed by, and won’t bring up even when they go to their doctor. It’s embarrassing to them to say they have these problems. We try to educate them that you’re there to help them and they have to open up and say they have these problems.

Now prolapse, you can actually feel this down in the vaginal area?”

David B. Robinson, MD: “When it becomes severe enough you will be able to not only feel it, but often see it.”

Barbara Nesbitt: “If they bring this up to their physician and then seek proper care they can go and have it corrected before this happens to them?”

David B. Robinson, MD: “Yes, but again they’ll want to be treated based on their symptoms. In other words, when I take someone with prolapse and propose surgery to her, I want to be sure that when I’m done she be minus some symptom that she came to me with. I don’t want to have her undergo a major surgical procedure just to make it look better to whoever is going to be examining her. I want to have them identify for me what symptom is it that this is causing, and what symptom is it you want to be rid of before they get into a surgical area.”

Barbara Nesbitt: “How do I go about finding the right place to go?”

Dennis Miller, MD: “There are a variety of resources, like OBGYN.net, and the Internet in general is a good resource. Generally, in most cities, there’s only going to be a small handful of physicians who specialize in the treatment of prolapse and incontinence. So that information should be readily available, even from your primary care provider, they generally will know. Experience is a great teacher, so going to an experienced practitioner who on a day-to-day basis treats incontinence and prolapse can be very important to getting the state-of-the-art care. That information is surprisingly easy to obtain, you just have to ask your primary care provider. If they don’t give you a good answer, find another source. But as I say, in most locales there’s only going to be a small handful of physicians who specialize in this area.”

David B. Robinson, MD: “One of the other resources they might want to use is the American Urogynecological Society’s website, www.AUGS.org, that has a roster of members and their locations, and those people are the people interested in the treatment of incontinence and pelvic organ prolapse.”

Dennis Miller, MD: “Barbara, you have to realize that a urogynecologist is someone who specializes in these disorders that have historically fallen between two specialties. Often an urologist will have a great deal of expertise about the bladder, but they don’t have the background in the contributors to the disease that are part of being a woman. And a gynecologist will often have a great deal of expertise in reproductive pathology, but do not have the experience in treating bladders. So the urogynecologist is someone who specializes in those things that fall between the specialties.”

Barbara Nesbitt: “Well, I think that we’ve educated women and I think that if they read this and follow the good advice that we’ve shared with them today, I think we’ve helped them. I thank both of you for your time.

Dennis Miller, MD: & David B. Robinson, MD: “Thank you Barbara.”