Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And our discussion today focuses on urogynecology surgical procedures. Joining me is Dr. Lia Miceli. She's a urogynecologist with AHN Women's Institute specializing in pelvic organ prolapse repair, urinary incontinence and vNOTES procedures. Dr. Miceli, it's a pleasure to have you join us today. I'd like you to start by giving us a little brief overview of pelvic floor disorders, the different types that you see, how common they are, and do you think that they're under-reported because so many people are hesitant to discuss them in the first place.

Dr. Lia Miceli: Hi, Melanie. Thanks so much for having me here today. I'm looking forward to talking about pelvic floor disorders. We also call them PFDs, because sometimes that can be a little bit of a mouthful. But just as an overview of what a pelvic floor disorder is, it's basically a group of problems affecting a lot of women and include any of the organs and muscles in the pelvis or pelvic floor.

Common disorders in this category include pelvic organ or vaginal prolapse, urinary incontinence, and fecal incontinence. Here in the Urogynecology world and looking at pelvic floor disorders, we see some of the more uncommon things as well, like bladder pain syndrome, recurrent UTI, congenital or structural anomalies of the vagina or pelvic organs, that really aren't associated with fertility or infertility. And we also take care of patients with complex birth trauma requiring subsequent intervention or reconstruction. So, it's a really common group of disorders. Up to 80% of women can experience some kind of pelvic floor disorder in their lifetime. And I do agree that historically these have been incredibly under-reported.

I think luckily thanks to media outlets like this and just an overall push to take care of women with pelvic floor disorders and increased awareness, we've been busy. And I hear all the time that it's kind of like, "I know my mom had this and she never talked about it," or "I learned about this from an aunt on the down low." But I'm feeling really reassured that women are feeling more empowered to seek care for these problems.

Melanie Cole, MS: Dr. Miceli, as primary care and gynecologists/OB-GYN are sometimes the first people to see these patients with these complaints or have these discussions, you're speaking to other providers here, what would you like them to know about approaching women at the very beginning? Because as we just said, sometimes they're hesitant. This is an uncomfortable thing to discuss, especially if you're discussing fecal incontinence, urinary incontinence that affect the quality of life of the woman so much. So, what would you like to say to other providers about starting with these women and hearing them out, hearing their symptoms, what they should be looking for?

Dr. Lia Miceli: Yeah, absolutely. I think it's important for these problems because they can be very bothersome. It's just to give women the space to talk about it. You know, allow the time and patience and, importantly, to ask. We have really big long questionnaires that we give out and that we discuss at the subspecialty level. But even just asking, "Do you have any problems with your bowels or your bladder? Do you have any issues or things that are bothering you in your pelvis?" Or any way that you'd want to phrase that. It doesn't have to take a lot of time and you'd be surprised how often the answer is yes. And you have a lot of resources in terms of where to go at the next level.

I will say I think a lot of patients and a lot of providers would like to maintain their patients within their own practice. And so, for many of these things, prolapse, urinary incontinence, fecal incontinence, first-line therapy can 100% be initiated at the primary care or the general OB-GYN level. And I know I've participated in some of these and my partners have as well, but we've done some outreach lectures on how to make that happen. And I know any of us are more than happy to answer any questions that you'd have or are available for referrals as well.

Melanie Cole, MS: So before we get into some of the exciting surgical advances in the Urogynecology world, non-surgically, when you're talking to these providers. Tell us a little bit about some of the things that are going on, because it's changed over the years for sure, and there's plenty of conservative management and things now, even pelvic floor physical therapy is a very specialized field. So, speak about what goes on in the non-surgical field first.

Dr. Lia Miceli: For sure. I think the first is kind of finding out how bothered a patient is, because although these disorders can be extremely troublesome, they're often taken care of in a more elective sense rather than an urgent or an emergent sense. And so, you know, we'll often see patients who, yeah, they do factually have prolapse. They say, "I am totally unbothered by this." And so, I'm happy to provide education, but we don't really have to act unless patients are bothered.

At the early stages of things like prolapse, urinary and fecal incontinence, we have really great partners in our care. Just like you mentioned, with the pelvic floor physical therapists, they are excellent at working to strengthen the pelvis. And provide a range of exercises in women with early stage prolapse. It doesn't often reverse the prolapse per se. Some studies can suggest that in younger women, maybe you can go up potentially by a stage intermittently, but it can relieve some of the symptoms of pressure.

Our pelvic floor physical therapists are really excellent in the worlds of incontinence. They treat both stress incontinence, which is more of a low-tone problem. That's where you think about the exercises and the Kegels and things. And then, also urgency incontinence, which can sometimes be a high tone or a control problem. The pelvic floor physical therapists shine in the realm of bladder and pelvic pain working on the muscles. They're very specialized in that area, and also working in women with fecal incontinence. So, they're a great adjunct in our care.

There are a variety of nonsurgical options, I'm not kind of start by disorder for prolapse. We do talk to women about pelvic floor physical therapy or even something like a vaginal insert or pessary if they wanted to avoid a prolapse repair, even if they have more advanced stage. This is often a disorder seen in women who are older. And with age comes medical comorbidities. So, everyone may not be the best surgical candidate. So, we do have pessaries and things like that to help those women.

Some non-surgical options for incontinence really depends upon the kind that you have. For stress incontinence, like I said, physical therapy's an excellent option as well as certain vaginal inserts like Poise Impressa, pessaries and things like that. But the inserts tend to not work quite as well for that. For urgency incontinence, non-surgical things is pelvic floor, physical therapy, a lot of dietary modifications, and also medication management. We can get into the procedural management of that later, but the medications are kind of our first line.

And then, for fecal incontinence, a lot of it is non-surgical actually, and then focused on diet, eliminating the amount of fatty foods in the diet, caffeinated beverages and alcohol, and adding a fiber supplement. That can help a lot of people actually just modifying their diet, looking at lactose and things like that, and the fiber as well as going to see physical therapy. So, it can be very impactful just with small changes. And so if you have the information, you can really empower patients to do a lot on their own there.

Melanie Cole, MS: So many options, so many tools in your toolbox these days, Dr. Miceli. So, let's get into some of the surgical interventions. Any novel surgical techniques you'd like to speak about for these disorders we've been discussing?

Dr. Lia Miceli: So, kind of in a general sense, all the surgeries that we provide for pelvic organ prolapse or incontinence are considered to be minimally invasive. The bread and butter Urogynecology really is focused on vaginal surgery and we are able to access the pelvis and strong ligaments in the pelvis, even just looking from a vaginal vantage point.

Where the novelty comes there is actually there are some procedures where we are able to do more complex reconstructive work and even excisional work, like for hysterectomy or complex adnexal masses, using endoscopy via the vagina. And the procedure that I'm referring to there is something called vNOTES, that stands for vaginal natural orifice endoscopic transluminal surgery, which is why you can imagine we shorten it to vNOTES. But this is another tool that we have that can really achieve excellent reconstructive and suspensory results and help to manage via better visualization, complex disorders within the pelvis. This is something that I was lucky enough to train on when I was in Texas and something that I do offer to patients, but it's not only for prolapse. There are variety of providers offering this service to patients.

For prolapse, kind of in a more standard sense, we do offer both native tissue and graft-augmented repair via the vagina or via laparoscopy and robotics. We have some really robust techniques using graft augments, commonly called mesh. This is a separate category from vaginal mesh. This is safe studied and very effective, lightweight, polypropylene mesh that we can use in patients with or without a uterus. So, a lot of good options for our patients from a prolapse standpoint, and we really take care to tailor each patient's surgical options and plan to their specific anatomy, medical, history and surgical history as well. So, we take very tailored and individualized care of our patients.

In the realm of incontinence, we also do have mesh and non-mesh based procedures. Starting with stress incontinence, you know, the gold standard is something called a midurethral sling. It works 90% of the time and we all love it. It's a 20-minute surgery. but it is mesh-augmented. So in women who may be not a candidate for that, we can offer things like urethral bulking. And it seems like we kind of have something to offer everybody there.

In the world of urgency incontinence, the procedures are absolutely incredible. And they are focused really on the neurophysiology of bladder continence. And so, we can inject Botox into the bladder. We actually can do that in the office, and you can get that done twice a year. Highly effective, 85% to 90%. And then, we also have a great long-term management strategy with something called sacral neuromodulation, which is basically where we have a wire or an electrode that gets placed next to the third sacral nerve root and provides a pulsitile stimulation to significantly impact urgency incontinence for up to 12 years. And I say 12 years really, and that just means they need a battery change. So, it can be considered to be a long-term fix. We tell the patients they can try that before they buy it in a colloquial sense, whereas they have an office trial. And if it works, they convert to the full implant. And we actually have patients who want to convert to the full implant 90% of the time. So, lots of great options for all.

For fecal incontinence, the sacral neuromodulation is also highly effective. I would say in a general sense, we do less reconstructive work for fecal incontinence unless there is an obvious muscle defect, but the sacral neuromodulation works incredibly well.

Melanie Cole, MS: Wow. What an exciting time in your field, Dr. Miceli. There's so many options for people suffering from these kinds of disorders. Now, one of the important factors, and as you've touched on just a little bit, is the multidisciplinary need and approach for these patients, whether it's fecal incontinence or pelvic organ prolapse. After you've done your magic, then there are other people involved. Why don't you just speak about the multidisciplinary approach and how that is so important for quality of life and followup.

Dr. Lia Miceli: Absolutely. I would say that it's infrequent that any of these disorders occur in isolation or within a bubble, and definitely are impacted by a patient's medical history and comorbidities. For instance, it's like, you know, I can try my hardest to work on a patient's incontinence problem. But if they have really poorly controlled diabetes and their A1c is 11, there's little that I'm going to be able to do from a neurophysiology standpoint. So really, we're partnered with, in taking care of patients, our partners in primary care. We're often partnered with our colleagues in gastroenterology because things like fecal incontinence is highly impacted by the GI system itself, not just a structural outlet problem. And also, if patients have horrible IBS or constipation, prolapse repair can be quite challenging and often recurs given the chronic straining of that nature. So, a control of patient's medical comorbidities specifically, things like diabetes, chronic cough, constipation and inflammatory or irritable bowel are paramount in making sure that we're successful in our treatments and that our patients can have good long-term outcomes.

Melanie Cole, MS: Final thoughts, Dr. Miceli, for other providers, what you'd like them to know about all the exciting work that you're doing at AHN? 

Dr. Lia Miceli: We have a really incredible group here. There are five of us providing full-time care, and that's just on the physician side of things. We also do have a lineup of advanced practice providers. And I think all of us offer something different for our patients. We really try to focus on, like you said, multidisciplinary care and often are doing cases with our Oncology teams or Colorectal teams, just to really make sure that the patients get tailored individual care in an efficient manner. I think my partners are all very skilled and incredible people and who are doing a lot of things for women with pelvic floor disorders in the Western Pennsylvania area. So, I'm very happy to be here and proud to be a part of this group.

Melanie Cole, MS: Thank you so much, Dr. Miceli, for joining us, sharing your incredible expertise today. To refer your patient to Dr. Lia Miceli, please call 844-MD-REFER or visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.