Amanda Wilde (Host): Your uterus, bladder, and other pelvic organs are held into place by muscles and tissue. For many women, especially after childbirth, those supports loosen, which causes pelvic organs to fall out of place, and that is what is known as pelvic organ prolapse. It's fairly common, so we're talking about how to understand and address pelvic organ prolapse with urogynecologist, Dr. Nani Moss.

This is Transforming Your Health, the podcast from Trinity Health of New England. I'm Amanda Wilde. Welcome, Dr. Moss. It is great to have you here for this very important conversation.

Nani Moss, MD, MPH: Thank you so much for having me.

Host: Well, let's start with the basics. Statistics say one in three women will experience pelvic floor disorder. What is the definition of pelvic floor disorder?

Nani Moss, MD, MPH: Yeah. So in basic terms, the pelvic floor is a group of muscles that support the bladder, the vagina, the rectum, and the uterus. And so, these muscles, you can think of them as existing in a bowl-like structure, and this bowl sits in your pelvic bones and supports these structures. And so when I hear the term pelvic floor disorder or pelvic floor issue or pelvic floor disease, it really is a euphemism for conditions that affect these areas, such as urinary incontinence, urinary retention, pelvic organ prolapse, fecal incontinence, and constipation, to name a few.

Host: When I hear pelvic floor disorders, I usually think of leaking and problems with urination, but regarding Pelvic organ prolapse, what are the signs and symptoms that we might notice?

Nani Moss, MD, MPH: With pelvic organ prolapse, as we've alluded to a couple of times, it's really a loss of support of the tissues. When I'm speaking with patients, I'll commonly use an analogy of a room, or first floor of a house. So if you're standing, looking out the front door, imagine that's the opening to the vagina. And upstairs in the second floor is the bladder, and downstairs in the basement is the rectum. And then behind you, maybe in the kitchen, is your uterus. And so, pelvic organ prolapse is a loss of support of, say, the floor between the first and second floor, where the floor is caving in and that ladder is coming down, and maybe it's even coming down into the first floor room, and then it actually pushing out through the front door, or the floor over the basement is caving, or I guess, pushing up and that rectum is pushing up into the first floor room and out the front door. And even that uterus can fall and come down into the room that we're standing in and out the front door.

And so, signs of pelvic organ prolapse can be pressure in the vagina. It can be actually seeing a bulge of tissue. Sometimes patients will say, you know, "When I'm wiping after urinating, there's just something extra there," or "In the shower, when I'm bathing myself, I'll feel something there that shouldn't be there, I don't think." Sometimes I'll have patients sent to me who on their gynecologic exam, their gynecologist noticed that they have prolapse. And so, they come in and say, " Hey, I was told to just show up," not as concerned about those patients because, again, they don't have any bothersome symptoms. And that's really the hallmark of pelvic organ prolapses, is a bothersome problem associated with this loss of support of these structures.

Host: So if you are not having symptoms, should you still act on this change?

Nani Moss, MD, MPH: So, because pelvic organ prolapse is not a life-threatening or dangerous condition, with the caveat being if your pelvic organ prolapse is so advanced that you're having a difficult time of emptying your bladder, and because of that lack of fully emptying your bladder, you're developing urinary tract infections, that's the one time where I say we must do something to address the issue. But I do have patients who come in and say, "Yeah, you know, I noticed this little bulge. It's not really bothersome. You know, what should I do about it?" In that case, we don't need to do anything. We can most certainly keep an eye on it. I would say though, if you're at all concerned, please go and see a doctor, and that person should point you in the right direction.

Host: Is it something that could be not bothersome to start, but get worse over time?

Nani Moss, MD, MPH: Most certainly, the prolapse doesn't occur overnight. And a common thing I hear from patients is, "This happened last week when I was doing X." You know, "I was in the garden and I felt something." And on exam, you know, there will be pelvic organ prolapse. And in those cases, this didn't just happen as that person was gardening. This has been something that's been developing for years, and it just so happens that last week, the symptoms became more of a problem for that individual.

Host: What causes pelvic organ prolapse? I mentioned pregnancy. I know that's a strain on the muscle, so you can sort of understand the loosening that might happen. Are there other factors? Does family history play a role at all?

Nani Moss, MD, MPH: So, there are many causes of pelvic organ prolapse, and no one thing essentially causes it. So, patients who have connective tissue disorders where their tissues just may be weaker can develop it. Conditions that increase pressure on those pelvic floor muscles, such as pregnancy or having a baby can do this.

But other conditions such as obesity, chronic constipation, and even having a chronic cough can lead to pelvic organ prolapse. And while family history can play a factor because I do hear commonly, "My mom had this problem years ago," or "My sister had this surgery three years ago, and I didn't know if I would develop it. The hard part with family history is we don't know the complete picture. We don't have the sophistication in our testing to know exactly what genetic predisposition is going to lead somebody to develop pelvic organ prolapse. So while family history plays a role, I do have families where one person is just unlucky and develops it, and another doesn't.

Host: Is pelvic organ prolapse at all preventable? You mentioned obesity. So if that's a risk factor, are there others are within our control?

Nani Moss, MD, MPH: So in terms of prevention, unfortunately, we cannot do things like go back and genetically correct connective tissue disorders. People are going to want to have children. And these are things that we cannot change. But things that are in a patient's control are address your constipation issues. Go and see your primary care doctor, you know, a gastroenterologist. If you have a cough, a chronic cough, go and treat the underlying conditions that may be contributing to that chronic cough. Obtaining better control over your asthma, quitting smoking, treating heartburn, and then, like most things in life, trying to avoid becoming overweight or obese can also help prevent pelvic organ prolapse.

Host: So, those are a few things you can do. But as you said, we don't even know exactly who's going to get it, how much is connected to lifestyle, how much is connected to family history. If you have pelvic organ prolapse, is it treatable?

Nani Moss, MD, MPH: The good news is, yes, it is treatable. So, we have both non-surgical as well as surgical options to help treat pelvic organ prolapse. As I mentioned, it's not a life-threatening or dangerous condition. So if patients are truly not bothered by their symptoms, it is okay to keep an eye on things. A common question I get is, "Will this get worse?" And in about 30% of patients, prolapse will get worse. I just have to explain to my patients, I don't know which patients it will get worse in. So, you know, if it does get worse, let me know and we can talk about readdressing treatment options at that time.

Patients can do pelvic floor physical therapy. So, pelvic floor physical therapy doesn't make prolapse go away, but it can help the sensation of prolapse. And I generally recommend that to my patients who have symptomatic prolapse, but where it's still relatively, I don't want to say small, but still inside the vagina.

Patients can come to be fit for a pessary. A pessary is a little plastic or medical-grade silicon device that fits inside the vagina, and it helps to support prolapse. Just like vaginas and prolapse, pessaries come in different shapes and sizes. And so, it may take a little bit of trial and error to find the perfect pessary for a patient. And then, surgery is also a treatment option. As urogynecologists, we try to perform surgery using minimally invasive techniques. So, we'll commonly offer patients a vaginal approach or a minimally invasive laparoscopic approach to their treatment of pelvic organ prolapse.

Host: Now, you've mentioned that if you're experiencing symptoms, you should definitely see a doctor and at least have a way of monitoring the pelvic organ prolapse. But this can be a touchy subject, and can be uncomfortable to bring up with your doctor. Do you have advice for patients feeling nervous or uncomfortable mentioning what they are experiencing in their pelvic area during their doctor's visit?

Nani Moss, MD, MPH: I think the most important thing to remember is your doctor is there to help take care of you. And so if something is bothering you, your doctor is going to want to know about that. And even if it's uncomfortable or embarrassing to bring up, it's okay to do it. The doctor's office, in that appointment, it's a very safe space. And so, I hope patients do feel comfortable, just if something's bothering them, to definitely mention it. Sometimes I hear patients say, you know, my primary care doctor is, you know, a male or it's the opposite sex of what I am. And in those cases, I kind of try to say, "Do we need to find you a different provider who you will be more comfortable with talking?" Because sometimes, having a doctor of the same sex that you identify with can be helpful and make discussing more difficult topics easier to do. But bottom line, doctors want to take care of their patients. So if something is bothering you, please let one of your providers know.

Host: It may also help if we debunk some myths. Now, I know there are some common misconceptions related to pelvic organ prolapse. What do you hear from patients?

Nani Moss, MD, MPH: I think a common misconception I hear is, "I had a baby," or "I'm getting older," and this is just a fact of life, that pelvic organ prolapse or other pelvic floor disorders happen because of these conditions. And the truth is that, yes, they can happen because of having a baby or getting older. But you do not have to live with it. And so, seeking care is really important.

The other thing that my patients ask me is, "How common is this?" And that comment always surprises me because I have to look at them and say, "This is what I do all day." I see patients in the office four to five days a week, depending if I'm in the operating room. So, these are common conditions. So, please do not be embarrassed. And if they are bothering you, please seek medical assistance.

Host: So, my takeaways are you do not have to live with pelvic organ prolapse and there are things you can do proactively for prevention. But also if you're experiencing pelvic organ prolapse, to improve your quality of life. Thank you so much, Doctor, for highlighting symptoms and treatment and also busting some myths.

Nani Moss, MD, MPH: It was my pleasure. Just like with any medical problem, if something is bothering you, let somebody know so that they can help guide you in seeking care with the correct provider.

Host: Thank you for the great advice and the great education. That's Nani Moss, urogynecologist at Trinity Health of New England. For more information, visit TrinityHealthofNE.org. That's Trinity Health, O-F-N-E.org/women. If you found this podcast helpful, please share it with others, especially on your social media. Thanks for listening to Transforming Your Health Podcast from Trinity Health of New England.