Gina Kaye (Host): This is Expert Insights with the Carle Foundation Hospital. I am your host, Gina Kaye. And joining me today is Dr. Abhilasha Tangada. For this podcast, we are going to dive into a discussion about urogynecology. I think before we jump into the questions, let's do a little backpedaling and talk about what exactly is urogynecology.

So, Doctor, if you could kind of give us an overview of that, I think that would be very helpful.

Dr. Abhilasha Tangada: So, urogynecology came about as a subspecialty that combined certain aspects of gynecology and urology that is focused on the diagnosis and the treatment of pelvic floor disorders in women. The most common things that people are aware of is urinary incontinence in women and pelvic organ prolapse.

Host: We appreciate you joining us today. So, let's just dive right into our questions then. How about start with review the spectrum of pelvic floor disorders?

Dr. Abhilasha Tangada: So, pelvic floor disorders is a huge umbrella term that encompasses a spectrum of conditions that result from either dysfunction or weakness or injury of the pelvic floor muscles, the connective tissues, and the nerves. And the manifestations can then be impaired control of either the bladder, the bowels, any sexual dysfunction, abnormal descent of pelvic organs.

Host: And if you were to compare conservative and surgical management strategies for pelvic organ prolapse and urinary incontinence

Dr. Abhilasha Tangada: So, the first kind of component of looking at pelvic organ prolapse or urinary incontinence is to essentially think about it as a quality of life issue. That is why there are conservative measures and there are surgical management options. So while someone may have urinary incontinence or someone may have prolapse, if they are asymptomatic, meaning it's not affecting their quality of life, they don't even notice it's there, it's something that their gynecologist commented on during an exam, they may not have to do anything.

So, conservative measures range from what we call observation or expectant management to pelvic floor physical therapy, which would improve the quality of the pelvic floor muscles, which then helps with symptom control. And then, the standard for a conservative management that is not surgery, whether for stress urinary incontinence or pelvic organ prolapse, would be a pessary.

Host: And can you explain that a little further?

Dr. Abhilasha Tangada: Yes. So, in terms of pelvic floor dysfunction, let's say. So if you look at pelvic organ prolapse, pelvic organ prolapse is the descent of one or more compartments of the vagina. Essentially, the vagina has lost support and now, for patients, it presents as a bulge. When they wipe, they feel extra tissue. They may notice a sensation of heaviness. They state that, "I feel like my innards are falling out," or something is falling out of me."

For those patients, conservative management would include improving the sensation of support, and that's where the pelvic floor muscles come into play. The pelvic floor muscles are what allow us to move around feeling supported, feeling like everything is in place. The non-technical metaphor that I use for my patients is think of prolapse like a breast, and think of your pelvic floor muscles as a bra. You can have a supportive bra or you can have a non-supportive bra women who wear bras know the difference. So, when you go to pelvic floor physical therapy, they improve the quality of your pelvic floor muscles, which means they improve that sensation of support.

Host: That's a wonderful description. I appreciate that. For this type of conservative or surgical interventions, is it mostly like women who have had childbirth or menopausal? Is there one that kind of leans over another maybe?

Dr. Abhilasha Tangada: So in terms of who gets conservative measures, most patients are given a choice. Typical factors that would lean towards conservative measures versus surgical management would be a patient who wants continued childbearing. So, we would recommend conservative measures until she has completed childbearing.

Other patients who are higher risk for surgery, if they are a high complication risk, you know, poor medical care, poorly controlled diabetes, significant cardiac risk factors, those patients, we would recommend conservative management with a pessary.

Host: I assume that there are best practices for pelvic floor disorders. Can you summarize some of those for us?

Dr. Abhilasha Tangada: So, current best practices for pelvic floor disorders have a few components to them. There's a kind of a lifestyle prevention component. There's an assessment component, as well as a treatment component. Essentially, in terms of prevention and lifestyle, the best practice that we can promote is essentially healthy living. And then, on top of that, the one kind of recurrent risk factor that we notice is patients who have a history of chronic constipation with chronic straining. So, avoiding constipation, improving your diet, whether it's fiber supplementation, whether it is just dietary fiber or activity, that's one thing that we would recommend.

In terms of the next component, assessment. In terms of evaluation, when you see a practitioner, we will do a full pelvic exam. But beyond just a general pelvic exam, you would get with a GYN. It also includes evaluating the anterior vaginal wall, the posterior vaginal wall, and the apex. So essentially, the supports of the vagina. Once the patient has been evaluated, then current best practices include offering a patient the entire spectrum of treatment options, ranging from conservative management to surgical management. And then, based on the patient's current health status, based on their physical exam, and based on patient's current lifestyle goals, that is when you have the conversation with the patient. It's shared decision-making, and you move forward with treatment.

Host: And then, finally, can you opportunities to optimize the patient care pathway?

Dr. Abhilasha Tangada: I think in terms of opportunities to optimize the patient care pathway, I think, first, is creating a conduit between primary care and the specialist or the subspecialist to be able to reach patients. I think creating education for primary care practitioners so that they are able to better counsel patients on what prolapse is.

Prolapse, when a patient notices prolapse, is pretty alarming. And so, if you're able to see your primary care, who is the first person usually a majority of my patients see before the gynecologist, it's important to counsel the patients that what they're seeing is not dangerous. Prolapse presents like a bulge or like a mass coming out of the vagina. But it isn't a mass. So, anytime a patient sees anything that is mass-like, they automatically assume cancer or something severely wrong. And primary care, I think, would be huge and play a large role in allaying those fears until the patient can get to us, and we can evaluate and provide further options.

Host: I'm really glad you said that because that was one of the other questions that I had. I think it's difficult when a patient presents with a problem and they just don't know who to call or who to tell first. So, knowing that maybe their primary care provider is their first step is good, and then they can refer on from there.

Dr. Abhilasha Tangada: Yes. It's either primary care, or if they have a gynecologist, they can go to their gynecologist. Either one would be the place to start.

Host: I think that was all the questions that we had. Is there anything else that you would like to summarize for this topic?

Dr. Abhilasha Tangada: A lot of patients who hear about prolapse or the way that prolapse is historically referred to is the historical terms were based on the compartment of the vagina, and the structure adjacent to it.

So for example, if somebody had weakness of the front wall of the vagina, they were told that they have a bladder prolapse or a cystocele. Those were historical terms that were used. Many of the patients that I see then come to me thinking that their bladder is actually, like, exposed and prolapsing outside of their vagina, which is not the case. And so, appropriately so, they are alarmed. And then, they don't understand why they don't have an immediate referral or this is not an emergency.

I think the biggest point that I would like to get across is that when we talk about prolapse to patients, if we kind of step away from those historical terms of bladder prolapse or uterine prolapse, or rectocele or cystocele, but use terms like the front wall of the vagina or anterior vaginal wall prolapse, apical prolapse, posterior vaginal wall prolapse.

Host: Okay. Thank you very much. I appreciate all that information. That's very helpful.

For more information and to get connected with one of our providers, please visit carle.org. That's C-A-R-L-E dot O-R-G. Or for a listing of Carle providers and to view Carle-sponsored educational activities, head over to our website at carleconnect.com.

That was Dr. Tangada. For more information and to get connected with one of our providers, please visit www.carle.org. And for a listing of Carle providers and Carle-sponsored educational activities, head over to carleconnect.com. If you enjoyed this podcast, please share it on your social channels and check out our full podcast library for more topics of interest.

I'm Gina Kaye. And this is Expert Insights: Life-Changing. Thanks for listening.

All content of this podcast is intended for general information purposes only, and is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. Please consult a medical professional before adopting any of the suggestions discussed on this podcast episode.