Deborah Howell: So, a majority of women with pelvic organ prolapse are asymptomatic and may be able to relieve some symptoms without surgery. Today, we'll learn more about surgical options for pelvic organ prolapse. I'm Deborah Howell, and my guest today is Dr. Allen Mehr, a Board Certified Urogynecologist and Reconstructive Pelvic Surgeon at the Pelvic Health and Wellness Center.

Welcome, Dr. Mehr.

Allen Mehr, DO: Hi, Deborah. Thanks for having me.

Host: Wonderful to have you back. So, in sort of Part 1 of this little episode here, we talked about pelvic organ prolapse. Could you regroup for our audience?

Allen Mehr, DO: Yeah. So, we kind of talked about essentially non-surgical management of pelvic organ prolapse. So we discussed watchful waiting, because the majority of these women are asymptomatic. We talked about pelvic floor physical exercises, which are typically done on your own as well as working with a physical therapist, for those of our patients that need a little bit more help. And we also talked about pessaries, which are non-surgical devices to help with prolapse symptoms.

Host: Okay. When is surgery for the management of prolapse indicated?

Allen Mehr, DO: You know, it all comes down to symptoms. If it's bothering our patient, it's bothering us. And although there are different stages and different kind of degrees or grades of prolapse, it doesn't necessarily impact every woman the same. So, if the symptoms are bothersome enough, then we'll offer all the treatment options.

Host: I suppose you go with the pessaries first, before you jump to surgery. Are there any contraindications to pessary use?

Allen Mehr, DO: That's a great question. So, you know, a pessary is not necessarily right for every woman. It is a non-surgical option, so I always present it, but I also offer the surgical options as well. It's kind of a la carte or choose your own adventure. And contraindications to pessary use, I mean, they're, they're very well tolerated. I would say if someone has an active infection or if there's a risk for malignancy or cancer, or if it's someone who potentially has some cognitive impairment or dementia to where they could forget the pessary device; I would say those are contraindications, but there's very few absolute and we're able to get a lot, most, majority of women actually fit for a pessary.

Host: Okay. Now, when is surgery for management of prolapse indicated?

Allen Mehr, DO: If the patient's symptoms are bothersome enough to her and she's like, you know, I've tried a pessary or, you know, I don't, I don't think I could manage a pessary and it's impacting her quality of life and she really wants something done about it. I think that's the right time for prolapse surgery.

Host: Okay. And what kind of surgeries are available?

Allen Mehr, DO: Surgeries really are kind of broken up into, I would say, two big tiers. There is reconstructive surgeries and then there are obliterative surgeries. So, reconstructive surgeries kind of recreate the natural shape of the vagina and allow a woman to remain sexually active, specifically to continue to have penetrative sexual intercourse.

Whereas obliterative procedures are for those women who are not sexually active; you know, they're widowed or they're much older and just don't have any plans for sexual intercourse. And that's where we actually kind of close the top two thirds of the vagina. And it allows us to kind of offer a wide spectrum of therapies for women kind of along their entire life spectrum.

Host: Sure. Well, you spoke to this a little bit just now, but which kind of surgery is right for me?

Allen Mehr, DO: Right. So, you know, it's a risks-benefits discussion. I would say if we're focusing on reconstructive surgeries; let's say our patient wants to remain sexually active. There's two types. There's the repairs that we do with your own tissues, and then there's the surgeries that we do with mesh. And there's a trade off.

So repairs with your own tissues, the good thing is, you know, it's your own tissues. Kind of the downside to that is also that it's your own tissue. So if we think about prolapse like a hernia, in those women where we go and do the repairs with their own tissue, there's a little bit higher risk of recurrence.

But, you know, you have the benefit of not utilizing a permanent material. Whereas on the other side of it, you know, the repairs with mesh are more durable because we're not using your own tissues. But then the kind of the trade off there is that there are some important considerations and complications when you utilize a more permanent material.

Host: So each woman should have this discussion with their primary care physician, right?

Allen Mehr, DO: Absolutely. And I think when you're at a place where you're considering surgery, I think it's important to kind of meet with a subspecialist who does these types of surgeries and kind of have a little bit more of a nuanced discussion as to what the specific risks of each of these approaches are.

Host: Okay, good enough. Dr. Mehr, are surgical approaches available for women with medical comorbidities?

Allen Mehr, DO: Absolutely, a lot of these surgeries that we do for prolapse, whether reconstructive or obliterative surgeries, they don't necessarily have to be done under general anesthesia. We can do some of these surgeries under regional anesthesia, similar to like a, an epidural someone would have during labor. So we can certainly tailor the surgeries to really help take care of women with more significant health conditions as well.

Host: Very good to know. I've heard about transvaginal mesh kits and lawsuits. Are those procedures still done?

Allen Mehr, DO: That's an awesome question. These transvaginal mesh kits, they kind of came out in the nineties and early two thousands. And then right around 2007, 2008 timeframe, I think the FDA put out this safety advisory and bulletin that really more studies were needed on these devices.

And in 2019 they were taken off the market and they're no longer utilized for really prolapse repair. I think those mesh kits are not the same surgeries as we do now for prolapse. There was a lot of excitement and you know, marketing of these devices to really being the cure all for prolapse. And I think kind of the training and implementation lagged behind the excitement. And unfortunately, it impacted a lot of women negatively. So we still get a lot of questions about that. But you know, they're no longer on the market, and they're not being utilized. I would say, kind of as a comparison, you know, those kits had high exposure rates, meaning the mesh would kind of come through the tissues, and it impacted maybe one out of eight women, which is pretty significant.

But these newer, our abdominal approach to these repairs has maybe two or three percent risk of mesh exposure versus that 15 or 20 percent risk.

So

Host: It's much better.

Allen Mehr, DO: Yeah, much, better.

Host: And you know, medicine is an evolving science, you know, we, we try things until they don't work or until a better alternative comes along. Is special training required to perform procedures today that use mesh or biologic grafts?

Allen Mehr, DO: There's really two approaches. I think OBGYNs can do an additional three years of training in a subspecialty called Urogynecology and Reconstructive Pelvic Surgery, or just Urogynecology for short, but there's also urologists that do an additional two years of training to be able to do these procedures and offer these treatments.

Host: Okay, and are there effective surgical options for women who prefer to avoid hysterectomy?

Allen Mehr, DO: Yes, actually, as you said, this kind of specialty is evolving. We know that the uterus is really not the culprit when it comes to prolapse.

So, we are able to do a lot of these suspension procedures and support procedures without having to remove the uterus. And there are some benefits to that, you know, less operative time, less bleeding risk. And some women don't want to have a hysterectomy because that carries its own risks as well. So, we certainly can do procedures called hysterepexies, where we support the top of the vagina without having to remove the uterus.

Host: Oh, okay. Truth or myth? Does a hysterectomy treat prolapse?

Allen Mehr, DO: Certainly a myth. If anything, actually a hysterectomy has been shown to be risk factor for prolapse progression. So when someone who has mild prolapse symptoms and they have a hysterectomy, it can actually make it worse because a lot of those support structures that help hold up the top of the vagina actually connect to the cervix and the uterus, and those are cut during a hysterectomy. So it certainly doesn't help treat prolapse and if anything can make it worse.

Host: All right. 500 dollars. It's myth. All right. There we go. I've heard you can develop urinary incontinence after prolapse surgery. Is that true?

Allen Mehr, DO: Specifically when you're looking at kind of prolapse of the bladder, if you imagine the bladder kind of coming down, sometimes what that does is it creates a little bit of a kink in the urethra. So imagine you're drinking from a straw, you're blowing through a straw and you were to bend it in half, the airflow would stop or, you know, you wouldn't be able to drink anymore. And now when you kind of correct that prolapse and you put everything back into its normal anatomic position, the straw is more straight. So now it's a lot easier for women to leak. And that's when we're talking about surgery for prolapse, that's something that we certainly kind of evaluate prior to surgery to better individualize the counseling for that woman.

Host: That's an excellent visual. What are the complications of, I'm going to call it POP surgery?

Allen Mehr, DO: Complications of POP surgery are very similar to most surgeries. So, you know, you can have bleeding, infection, injury to surrounding organs and structures. So it's certainly not without risk. Those risks are small, I would say less than one percent. But it's never zero, right? If it happens to that individual, it's a hundred percent for that individual, certainly. But it carries the typical risks of any surgery.

Host: How should recurrent POP be managed?

Allen Mehr, DO: Recurrent prolapse you know, our surgeries certainly aren't perfect and that's kind of really where the counseling plays in, but let's say a patient has had or a woman has had surgery for prolapse and she has recurrent symptoms, we would offer the whole, the entire spectrum of surgical and non-surgical treatment options.

So, you know, we could re-approach physical therapy, or if the symptoms aren't bothering her, watchful waiting. The pessaries are still an option, and we could explore surgery a second time as well.

Host: For any woman listening right now, can you just walk us through how is a woman going to feel before treatment versus after treatment?

Allen Mehr, DO: Great question, Deborah. So, I would say, I have a lot of patients that come in and they're not able to do the things they want to do. This is impacting their ability to golf or leave the home or really kind of participate in their social activities to kind of that extent that they really want to and to stay active.

And I feel like, a lot of times after treatment, whether surgical or non-surgical, we kind of give women their confidence back and they can resume those activities. And really it all comes down to quality of life. I feel like we're, we're able to help a lot of women with that.

Host: That is a huge, huge gift. I can't think of anything more debilitating than not being able to do what you love.

Allen Mehr, DO: That's right.

Host: Is there anything else you want to add to our conversation? Anything on the horizon?

Allen Mehr, DO: Not particularly. I think, uh, you know, our field continues to develop and we're coming up with some new and interesting ways to treat overactive bladder or, you know, having to go often or having to void frequently. So there's some interesting things coming down that pipeline, but in terms of prolapse, I haven't seen anything terribly new or exciting this last year.

Host: All right. Well, this is all such good information, Dr. Mehr. Just a pleasure to have you with us. Thank you so much for being with us.

Allen Mehr, DO: Thanks for having me, Deborah. Have a good day.

Host: You too, and that wraps up this episode of the podcast series from Deaconess the Women's Hospital, a place for all your life. For more info, please visit deaconess.com/pelvichealth.

Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women's Hospital podcasts. For more health tips and updates, follow us on your social channels. I'm Deborah Howell. Thanks for listening and have yourself a terrific day.