Joey Wahler (Host): It can cause significant pain. So we're discussing pelvic organ prolapse, also known as POP. Our guest, Dr. Nahla Merhi. She's a Gynecologist and Urogynecologist with Silver Cross Hospital. This is Silver Cross Hospital's I Matter Health podcast. Medical experts bring you the latest information on health topics that matter most to you and your family.

Thanks so much for joining us. I'm Joey Wahler and hi there, Dr. Merhi. Welcome.

Nahla Merhi, MD: Thank you.

Host: Great to have you aboard. So first, in a nutshell, what exactly is pelvic organ prolapse?

Nahla Merhi, MD: As the name implies, pelvic organ prolapse is the herniation of one of the pelvic organs or more than one organ into the vaginal area. So it could be the uterus, it could be the bladder, it could be the rectum, the bowels, or all the above herniating through the vaginal area of the patients.

Host: And just how common is this condition in the U.S.?

Nahla Merhi, MD: So common, it is so common worldwide. It is estimated to be one in four women over the age of 40. And that number increases as the patient ages. When you go over the age of 50, one in three women may have one kind of pelvic organ prolapse. So it is very common, more than women think.

Host: And yet the irony is, am I right, Doctor, that many people are unfamiliar with this, aren't they?

Nahla Merhi, MD: Many patients suffer from it, but silently. So women, instead of addressing the issue with their doctor, they're just embarrassed to talk about it, or sometimes they're just scared that maybe they need a big surgical procedure, too major, that they're so scared to even address the issue. That's the reason why many patients go without treatment.

And they shouldn't, because it can affect their life every single day and their activities every day. So the impact is big and patients should know about it and should have it treated.

Host: Absolutely. So we're talking here about the merging of organs, if you will. How does that happen?

Nahla Merhi, MD: Typically there is a tear in the tissues. The tear in the tissues, the pelvic floor is like a layer of muscles that lifts the bladder, uterus, and rectum. So imagine that floor is torn. You have drop in the organs inside the, into the vagina. It happens from childbirth, a difficult vaginal delivery, or from lifting heavy.

Some patients don't have kids, but have herniations and have prolapse. It could be also from their jobs, when they are asked to lift excessively heavy objects. And sometimes it's genetic, sometimes chronic cough, overweight, anything that puts pressure on that pelvic floor and keeps the tissues weak and then they tear, and then you have that hernia.

Often, the insult happens years before the woman sees the prolapse. So a woman could have had her kids, at the age of 20, 30, but she presents with the prolapse in her 40s, 50s, 60s. So not always the problem is seen right away. It can be seen years later.

Host: Interesting. So what are the symptoms of this?

Nahla Merhi, MD: Patients can come with say, Oh my God, I have something. I have a ball. Is it cancer? I said, no, it's not. But it is a ball, a bulge that they feel it at the opening of their vagina. It's uncomfortable. It can be sometimes even difficult to sit comfortably. Patients also learn to push the prolapse sometimes to be able to empty their bladders or have to empty their bowels.

When it is excessive and it is completely outside the body, the patient simply can't sit comfortably, can't even walk, and it can affect obviously intimacy. So it can affect everything. Often the prolapse can also affect the bladder function and the bowel function. So women with prolapse often have also urinary incontinence or stool incontinence.

So often it goes hand in hand. So patients could present with incontinence or present with the bulge and they're related to each other.

Host: Gotcha. And so when you're using words like hernia, bulge, this sounds like it's basically the female version of a male hernia, right?

Nahla Merhi, MD: Kind of, except that the male hernia is typically different and the woman is not supposed to have anything coming outside her vagina, but it is equivalent to a man's hernia. It is equivalent to a hernia that's in the abdomen. You have a tear in the tissues and then the intestines come out. So it's exactly the same way and treated, honestly, the same way also, just from a different part of the body.

Host: And when you say that risk factors include excessive lifting and that women who've given birth are more prone to this, is the birth part from all the pushing and all the stress on that area that goes on during child delivery?

Nahla Merhi, MD: That's correct. However, many women push hard to have a baby vaginally, and then they have a C-section, and those women are also prone, because just the fact that they had pushed, even though the delivery was a C-section, has already torn some tissues. And also the weight of the pregnancy on the pelvic organs, even if the woman, as I said, did not have a vaginal birth, can also affect the tissues and create some micro tears that get bigger and bigger with wear and tear.

Host: Gotcha. So, what about treatment? What are the options when this occurs?

Nahla Merhi, MD: When the prolapse is small, we try to have the patient do pelvic exercises. We send them to pelvic floor therapists who can strengthen the muscles, Kegel exercises to try to see if that strengthening of the muscles will pull the tissues up. But when the tear is big, it is a tear. You have to fix it.

You have to stitch it. So often it is a surgical procedure. If it is mild to moderate, we do it transvaginally, 99 percent of the time in the surgery center as outpatient. It does not require hospitalization. You don't have to stay in the hospital. Essentially, it is restitching the torn tissue.

Whenever the prolapse is really big, where the woman has everything outside her body, like all she has to do is open her legs and you see all her organs. This is an advanced prolapse where you have to push everything. And if you stitch it, it fails. It's so weak, it's like stitching weak tissue to weak tissue, they're gonna fail again.

In that case, we need to treat it like a hernia, just like the man's hernia surgery, robotically by strengthening the tissues using a hernia mesh to lift everything up and keep it in place. So in that case, we do not use the vaginal meshes that we're warned against by FDA. I know everybody says, don't use meshes, don't use meshes.

Yes, I don't, we don't here at Silvercross use vaginal meshes because they were warned against, but hernia meshes are different. The prolapses that are advanced are treated robotically with a hernia mesh just like a man's hernia, to lift the organs and keep them up in the pelvis as they should be. And this is also outpatient, robotically, with tiny incisions in the abdomen.

You do not stay in the hospital. You go home the same day. And the pain, surprisingly, is so minimal that patients come back after their first visit saying, I'm shocked. All that was done with only two days of pain. I needed only two days of pain medications. Some patients don't even take narcotics for that.

They just take over the counter and in four or five days you're driving. Most patients say, why did I even wait? I should have come way, way earlier. I should not have suffered. It wasn't bad. I'm gonna tell all my friends. And that's how we're getting busy. And that's a good problem.

Host: Yeah, it sounds like you women need to talk to each other more about this so that you don't wait as long and you know you're not alone, right?

Nahla Merhi, MD: Absolutely. Patients suffer. They're embarrassed. They think they're alone. You have to know one in three women. There's nothing to be embarrassed about. This is a one third of the population over a certain age. And it's not okay to live with it. It is fixable. It's easy. It's minimally invasive and it will change your life to back to normal.

 It is not a killer, but guess what? It is always life altering. Some women stop having social gatherings, some women stop going to their church or meet up with their friends, they're embarrassed if they have incontinence, if they are, if somebody is smelling that incontinence, whether it is urine or stool, and some women, like, stop having any physical, sexual intimacy with their partners.

It could be depressing. It is depressing. And that is one of the main reasons why women are admitted to nursing homes. Because incontinence and prolapse is the number one cause for admission of elderly women to the nursing homes. And the cost of the diapers, and the cost of the pads, all that is fixable.

Not always 100%, when it comes to incontinence after a certain age with women with dementia. But, most women with the ordinary prolapse are fixable in a minimally invasive fashion. They don't have to suffer with it. They're not alone. No need to suffer in silence. Talk about it. Ask your doctor, where shall I go?

Let the doctor refer you to the surgeons or to the urogynecologist who can address this issue and return back to your normal activity. It's not worth suffering in silence.

Host: No, absolutely not. Couple of other things. When you mentioned a moment ago advanced cases where things are very bad, how often is that largely, if not solely, due to the fact that the patient did wait too long.

Nahla Merhi, MD: Absolutely! When you fix something early, it doesn't get too big. Whenever it is early, it is fixable. And the surgery center, vaginal surgery, very small. The more you wait, the bigger the surgery. There's no need. It is no need. It doesn't happen overnight. Those advanced prolapses are because women waited and waited and waited for years.

That's how it became that big. I have patients who wait 20 years. What are you doing? Why? Sometimes they come with ulcers because the bulge that's outside the body with the friction with the clothing have ulcers and patches. And if they are on blood thinners, they start bleeding. All that from waiting. Not addressing the issue, not talking to the doctor about it, and not finding someone who can fix it. It is not necessary. The earlier you treat it, the easier is the treatment.

Host: And so in summary here, let me have you just please follow up on that, Doctor, about the fact that waiting doesn't just worsen the condition, but it can lead to other things that are only going to pop up because of that, right?

Nahla Merhi, MD: Absolutely. For example, patients who have the big prolapse, they don't empty their bladder well. So what happens? Reoccurring urine infections. They're admitted to the hospital every couple of months to treat infections of the urine, why don't we treat the root cause of the problem? So they start having reoccurring urinary tract infections, they start having ulcers in their area, bleeding from it, and more.

So, addressing the issue early is always useful. Once you have reoccurring urine infections, it becomes so difficult to treat. I'm sure many women can relate. I have been suffering with this issue. The bacteria are stuck now to my tissues and it is so hard to get rid of it. So the consequences of waiting are really, it is unnecessary.

It get to become more complicated. You start having more issues. It was prolapse, now it is incontinence, now it is infections, now it is ulcers. It gets way bigger than it should be and it is simply fixable. But also I want the patients to know that even if it's advanced, even if it is with ulcers, it is fixable, outpatient, minimally invasive, and to each patient there is a treatment.

We don't fix everyone the same way. If the woman is sexually active or not sexually active, we treat differently. If the patient is in a nursing home, she doesn't care about sexual activity, we push the prolapse and do something called closure of the vagina. That's okay. It's a small procedure done under local anesthesia.

So know that if you have an elder who has prolapse, who's too sick to be put to sleep for a robotic surgery, it's okay. We'll find something that works well for her medical condition, well for her lifestyle. So every prolapse surgery is geared toward each patient, is individualized so that each patient has what works well for her lifestyle.

A young lady, sexually active, we need to reconstruct the pelvis to as perfect as possible because she wanted to be great. She's still sexually active and that could be a 40 years old lady or it could be a 70 years old lady. Now, ladies are in their 70s, super healthy, active, many have sometimes a second marriage because they are widowed, so if they're sexually active, we'll fix it exactly to the way that will fit their lifestyle.

So, women should know that there is multiple treatment options. We don't treat everyone the same way and just address it. Talk about it. It could be, as I said, a small procedure under local anesthesia. It could be a robotic surgery. In all cases, it is outpatient, minimal pain and fast recovery.

Address it with your doctor. That is first thing you should do is pick up the phone and say, doctor, I'm suffering from prolapse. That's the first thing you should do. The rest is on us.

Host: Well, doctor, I think you've made yourself abundantly clear, yes?

Nahla Merhi, MD: Yes, I try. Awareness, awareness, awareness.

Host: Yes. Great job. Indeed. It's fixable and do not wait.

Nahla Merhi, MD: And here at Silver Cross Hospital, I just want to add, it is the place to go for whether it is a robotic surgery and whether it is a pelvic organ prolapse. As a Midwest Institute for robotic surgery, the place is the number one in Chicagoland in robotic surgery load. I myself, has been for more than 13, 14 years, an epicenter.

I teach surgeons, from all over the nation, who come to learn how I am performing those robotic surgeries and also proud and honored that recently designated by the Boston Scientific Company, which is the leading company for pelvic organ prolapse, and incontinence, pharmaceutical, to be the, the only and first, Virtual Center of Education for Pelvic Prolapse Surgery.

So I teach surgeons virtually and in person how to perform the surgeries for incontinence and pelvic prolapse. We've done more than 2,500 robotic cases, thousands, uncountable numbers of bladder slings and incontinence surgeries, so with the experience that we can add, with the technology that we have, we encourage the patients to call Silver Cross and ask about how to go about to see a doctor to treat for the pelvic organ prolapse and for urinary incontinence. We'll try to help and we've helped many.

As I said, patients say I should have come before and just pick up the phone.

Host: That simple. And by the way, congratulations on that unique designation. Folks, we trust you're now more familiar with pelvic organ prolapse. Dr. Nahla Merhi, keep up all your wonderful work. It sounds like you've got your hands full and a very busy schedule. Thanks so much again.

Nahla Merhi, MD: Thank you, Joey.

Host: And for more information, please visit silvercross.org/women'shealth. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being part of Silver Cross Hospital's I Matter Health Podcast.