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Pelvic Organ Prolapse
Around 50 percent of women will experience pelvic organ prolapse in their lifetimes, which occurs when the bladder, uterus, or rectum slips down into the vagina. Gena Dunivan, MD, director of the Division of Urogynecology and Pelvic Reconstructive Surgery, joins Dr. Huh to discuss the many effective treatment options for pelvic organ prolapse, which so many women experience but do not talk about. She emphasizes that a level of treatment should correspond with how much the condition is affecting the woman’s life—which could mean lifestyle changes, physical therapy, non-surgical devices, or surgery. The doctors encourage patients to seek only treatments covered by insurance.
Featuring:
Learn more about Gena Dunivan, MD
Gena Dunivan, MD
Gena Dunivan, MD is the Director, Division of Urogynecology and Pelvic Reconstructive Surgery.Learn more about Gena Dunivan, MD
Transcription:
Warner Huh, MD: Hello, everyone. This is Dr. Warner Huh again, Chair of the Obstetrics and Gynecology at the University of Alabama in Birmingham. And I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.
So today, we're going to talk about something that I know that you have not heard about, which is the topic of pelvic organ prolapse. And this is a topic that I think is more common than most people realize, particularly women, and one that is often reluctantly discussed. And so with me today to talk more about this is Dr. Gena Dunivan, who is a professor in the Department of Obstetrics and Gynecology, and is also the Division Director of Urogynecology & Pelvic Reconstructive Surgery here at UAB. She is also the Vice Chair of Mentorship and faculty development here in the department. And she was recently recruited to join the faculty this year from the University of New Mexico. And we're absolutely thrilled for her to be a part of our group. So welcome, Dr. Dunivan. Again, welcome to UAB in Birmingham.
Dr. Gena Dunivan: Thank you very much. I'm very happy to be here.
Warner Huh, MD: Okay. So let's dive right into it and talk about pelvic organ prolapse. Can you just share with the listeners about what this is and, you know, what are the symptoms and what are the risk factors? And I think this is something that I think many women are reluctant to bring up or they're embarrassed to talk about. But one of the major drivers for why I wanted to bring you on is to raise some additional awareness related to pelvic organ prolapse.
Dr. Gena Dunivan: Yes. Thank you. That is one of the biggest issues with a lot of pelvic floor disorders, but especially pelvic organ prolapse. This is a condition that many women are uncertain if it's normal or not, and they're often embarrassed about seeking care. So the most important thing I like to reassure our patients about is that they're not alone. This is actually quite a common condition. What that is is when one of the organs slips down from its normal position and it might bulge into the vagina. And so that can be the bladder, the uterus or rectum. Typical symptoms might be pressure or heaviness in the pelvic area, back pain and sometimes, as it progresses, difficulty emptying your bladder or your bowels. Sometimes women will talk about how they feel like they're sitting on an egg, for example.
One of the biggest risk factors is pregnancy and childbirth because it can change and weaken pelvic floor muscles. However, there are women that have never given birth that may experience pelvic organ prolapse. Other risk factors are associated with aging; changes in hormones like when we go through menopause; pelvic floor injury, also conditions that might put chronic strain on your pelvic floor, so that might be chronic constipation, coughing, heavy lifting.
Warner Huh, MD: So Dr. Dunivan, I think one thing that would be important for our listeners to know is like how common is this? I mean, do you know? Is there an estimate in the number of new cases or the number of women that live with pelvic organ prolapse at, you know, any given year? But also, if you could just comment on how do we manage this, because I think a lot of women who are listening to this would love to know what the treatment options are.
Dr. Gena Dunivan: Pelvic organ prolapse is surprisingly common. By the time women are in their 60s, about one in three may experience it. And by the time women are in their 80s, perhaps up to half of the women may be experiencing some symptoms of pelvic organ prolapse. So one of the great things about these conditions is that there are many, many treatment options, and that might range from just reassurance to a woman that was worried that something was wrong to more and more treatment options. So for example, one of the golden rules of prolapse is that if it doesn't bother you, we do not have to bother it. And so that might just be the reassurance piece. Also, sometimes small lifestyle changes like increasing fiber in your diet, losing a few pounds or exercising may help.
Once we get into more specialized treatments, that might include pelvic floor exercises with or without a physical therapist that's trained in that. There are non-surgical options such as a pessary. A pessary is a small plastic device that you can put in the vagina that helps hold things up. And then, there are many surgical options as well.
Warner Huh, MD: And can you just comment for me, just in general terms, what those surgical options look like for women?
Dr. Gena Dunivan: So there are surgical options that we can do, different route. So that one might be through the vagina and we use your natural tissues to help support things. And sometimes we can do another procedure where we do use a graft or a permanent material to help support the vagina.
Warner Huh, MD: Yeah. So again, I just want to kind of recapture some of what you said. I'm a little bit surprised, because you're saying up to 50% of women during their lifetime will experience some element of pelvic organ prolapse. Is that correct?
Dr. Gena Dunivan: Yes.
Warner Huh, MD: Wow. Okay. So again, I want the listeners to know that because ,again, I think this is, you know, an underrecognized problem that I think actually has multiple solutions, whether it's nonsurgical or surgical. And, you know, I think the intent of the podcast is just, again, raise simple awareness that this exists and many women are not alone. So one of the things I thought you might want to comment on, and I think some of our listeners are aware of this, is that over the last, I guess, maybe 10 to 15 years, there was widespread use of something called prosthetic mesh for these repairs, particularly for surgical repairs and that there was some controversy related to that. And I thought maybe if you could just touch upon that briefly and just share with the listeners what that controversy is.
Dr. Gena Dunivan: Yes. So there has been a lot of growth and development in this field over the last few decades. So there was a surgery that was developed to treat stress urinary incontinence, and that is the leaking when you sneeze or cough or laugh. And this new development really revolutionized how we do surgery for women that have this condition and what went from a long and complicated surgery that might involve days in the hospital as well as variable results. This new surgery that did involve placing a small piece of mesh under the urethra basically resulted in same-day procedures with great success rates.
Unfortunately, what happened is that some companies took that success and created mesh kits, which the idea was that it was large pieces of mesh that were placed in the vagina to help support it. And unfortunately, they were not studied well and they were marketed very widely, including to providers that may not have completed specialized training. And what was discovered is that when you put large pieces of mesh through the vagina, oftentimes by people that aren't necessarily as familiar with the anatomy as they should be, it resulted in a lot of complications and many women suffered.
So mesh is not good, bad, or indifferent. It's just a tool we use. And when it's used under appropriate and specific circumstances, it can be very helpful and result in great outcomes. Now, all of these "mesh kits" are no longer available. That's what you might hear when you read that the FDA recalled them. But mesh is still used in some of our procedures and this has been very well studied and is safe, especially in appropriately trained people.
Warner Huh, MD: So I want to just confirm what I'm hearing from you, which is that you're not saying that all use of mesh is necessarily bad and that there are selected times when used appropriately that prosthetic mesh is an important component for the surgical repair or pelvic organ prolapse. Is that correct?
Dr. Gena Dunivan: Yes.
Warner Huh, MD: All right. And I don't want to throw the baby out with the bath water, right? And so, you know, I think sometimes people hear mesh, "Oh, I'm going to steer clear of this," but again there's a clear need or use of mesh when appropriate.
Dr. Gena Dunivan: Yes, absolutely.
Warner Huh, MD: Okay.
Dr. Gena Dunivan: And I'd like to take this as an opportunity to pull from that example that I just explained and talk about something else that I see as evolving in our field. And that is what is being heavily marketed as vaginal rejuvenation surgery or vaginal cosmetic surgery. So this is being marketed directly to women and oftentimes women feel that this is going to help their prolapse symptoms, but it's not going to. The treatments that I described before are the well-studied treatments to help with pelvic organ prolapse.
What I often will remind my patients is that pelvic organ prolapse is a medical problem. And therefore, the insurances cover the treatment and that includes physical therapy, pessary or surgery. With these cosmetic procedures, women have to pay out-of-pocket. So often women are paying hundreds to thousands of dollars for treatments that are not well-studied and don't work necessarily for what they think are going to help the patient.
Warner Huh, MD: I guess what you're saying is that kind of buyer beware.
Dr. Gena Dunivan: Exactly. That if a provider is asking you to pay out-of-pocket for something, I would really encourage you to ask questions about why insurance doesn't cover it and what are the studies that actually support the use and the effects that it's going to have.
Warner Huh, MD: Yeah. And as I'm listening to you, it occurs to me that we probably would benefit from having a separate podcast on vaginal rejuvenation and, as a tangent to that, about its role again or absence of role in pelvic organ prolapse management. But again, just to kind of recapitulate what Dr. Dunivan is saying, is that, you know, beware, I think that the evidence is limited in this space. But more importantly, that you may be asked to pay a lot of money out-of-pocket really for a very unclear or questionable clinical benefit.
Dr. Gena Dunivan: Yes, I agree with that.
Warner Huh, MD: Okay. So, you know, one of the things I was just kind of curious about is that urogynecology, although the surgeries that they do is not new to gynecology, the profession itself is relatively new to the community. But can you just share with the listeners about what makes the Division of Urogynecology and Female Public Medicine and Reconstructive Surgery here at UAB unique when it comes to the management of these women with pelvic organ prolapse?
Dr. Gena Dunivan: I'm very proud of the division here at UAB because, as I mentioned, there are many treatment options available and women are best served by going somewhere where all of those options are fully available to them. Our team consists of providers, advanced practice providers, nurses, staff, and physical therapists that are all dedicated to providing women with pelvic floor disorders the best care possible. There is no one treatment to fit all women. Each patient that we see, we spend a lot of time individualizing their treatment plan because patients have different goals, they have different risk factors and they have different histories that affect how we decide with them what's the best treatment for them. Pelvic floor disorders are not a one-size-fits all and this allows us with all these treatment options to come up with the best treatment plan for each individual patient.
Warner Huh, MD: Yeah. So I kind of want to take that a little bit further because this is true for a lot of the gynecology services that are provided, is that it's no longer just a one single provider provides a one-size-fits-all management for women. You know, I think urogynecology and management of this problem, pelvic organ prolapse, requires a significant team-based approach. And I think that is what UAB in this department does quite well, is really looking at it from every angle and individualizing the management of these women. And so I appreciate your saying that because I think a lot of our listeners and women out there may or may not recognize that. It's not just one doctor or one physician or provider that's directing the care, but it's multiple people that have a role and impact in terms of the management of the individual woman.
Dr. Gena Dunivan: Yes, I totally agree.
Warner Huh, MD: You know, and the other thing I just want you to maybe just briefly touch upon is, you know, we did a separate podcast with Dr. Isuzu Meyer, who's one of your partners on the topic of stress urinary incontinence. And, you know, again, I think that people listening may be interested in this, is that oftentimes I've noticed that when you do these pelvic organ prolapse surgeries, you also do corrective surgeries to fix urinary incontinence or even fecal incontinence sometimes. I thought you may just wanted just to touch upon that briefly because, you know, I just want to make sure those two things are often combined at the same time.
Dr. Gena Dunivan: Yes. Pelvic floor disorders definitely travel in packs. So it may be that you have pelvic organ prolapse, so that can also affect how your bladder and your bowels work. So when a patient comes to see us, we assess for all of those to make sure that we're not just correcting one problem and ignoring another.
Warner Huh, MD: Any other closing thoughts or comments, Dr. Dunivan, that you want to share with our listeners?
Dr. Gena Dunivan: My closing thought would be that I really encourage women to talk to their providers about this. It is so often that I see a patient in the clinic that says that, "I'm so glad I finally found. Why did no one ever tell us that this field existed?" Part of it is that we are a newer field, but the other part is that there's such a stigma and shame that women carry that's associated with these pelvic floor disorders. And there's nothing to be embarrassed about. It's very common and there's a whole field that was developed to help you with these problems.
Warner Huh, MD: Yeah. That's like the perfect conclusion to this podcast, Dr. Dunivan, because that's the reason why I invited you, right? For our listeners to be aware that this is a highly common prevalent problem, but a problem that has multiple solutions and that women don't need to suffer and their quality of life doesn't need to suffer and that there's a way to manage this. And so that's really the goal for this podcast. I appreciate sharing your thoughts on this.
So again, I want to thank Dr. Dunivan, for updating us on public organ prolapse and its contemporary management. This was really a necessary and fantastic update on this topic. And again, I love driving further awareness on these various women's health issues with the community. So as always, please rate this podcast and we welcome any comments, particularly on topics that you're all interested in. And for more information on our urogynecology services or other gynecology services for that matter and expertise and other clinical services at UAB, please check out uabmedicine.org. And until next time, hope you all have a great day and we'll see you next month. Take care. Peace out.
Warner Huh, MD: Hello, everyone. This is Dr. Warner Huh again, Chair of the Obstetrics and Gynecology at the University of Alabama in Birmingham. And I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.
So today, we're going to talk about something that I know that you have not heard about, which is the topic of pelvic organ prolapse. And this is a topic that I think is more common than most people realize, particularly women, and one that is often reluctantly discussed. And so with me today to talk more about this is Dr. Gena Dunivan, who is a professor in the Department of Obstetrics and Gynecology, and is also the Division Director of Urogynecology & Pelvic Reconstructive Surgery here at UAB. She is also the Vice Chair of Mentorship and faculty development here in the department. And she was recently recruited to join the faculty this year from the University of New Mexico. And we're absolutely thrilled for her to be a part of our group. So welcome, Dr. Dunivan. Again, welcome to UAB in Birmingham.
Dr. Gena Dunivan: Thank you very much. I'm very happy to be here.
Warner Huh, MD: Okay. So let's dive right into it and talk about pelvic organ prolapse. Can you just share with the listeners about what this is and, you know, what are the symptoms and what are the risk factors? And I think this is something that I think many women are reluctant to bring up or they're embarrassed to talk about. But one of the major drivers for why I wanted to bring you on is to raise some additional awareness related to pelvic organ prolapse.
Dr. Gena Dunivan: Yes. Thank you. That is one of the biggest issues with a lot of pelvic floor disorders, but especially pelvic organ prolapse. This is a condition that many women are uncertain if it's normal or not, and they're often embarrassed about seeking care. So the most important thing I like to reassure our patients about is that they're not alone. This is actually quite a common condition. What that is is when one of the organs slips down from its normal position and it might bulge into the vagina. And so that can be the bladder, the uterus or rectum. Typical symptoms might be pressure or heaviness in the pelvic area, back pain and sometimes, as it progresses, difficulty emptying your bladder or your bowels. Sometimes women will talk about how they feel like they're sitting on an egg, for example.
One of the biggest risk factors is pregnancy and childbirth because it can change and weaken pelvic floor muscles. However, there are women that have never given birth that may experience pelvic organ prolapse. Other risk factors are associated with aging; changes in hormones like when we go through menopause; pelvic floor injury, also conditions that might put chronic strain on your pelvic floor, so that might be chronic constipation, coughing, heavy lifting.
Warner Huh, MD: So Dr. Dunivan, I think one thing that would be important for our listeners to know is like how common is this? I mean, do you know? Is there an estimate in the number of new cases or the number of women that live with pelvic organ prolapse at, you know, any given year? But also, if you could just comment on how do we manage this, because I think a lot of women who are listening to this would love to know what the treatment options are.
Dr. Gena Dunivan: Pelvic organ prolapse is surprisingly common. By the time women are in their 60s, about one in three may experience it. And by the time women are in their 80s, perhaps up to half of the women may be experiencing some symptoms of pelvic organ prolapse. So one of the great things about these conditions is that there are many, many treatment options, and that might range from just reassurance to a woman that was worried that something was wrong to more and more treatment options. So for example, one of the golden rules of prolapse is that if it doesn't bother you, we do not have to bother it. And so that might just be the reassurance piece. Also, sometimes small lifestyle changes like increasing fiber in your diet, losing a few pounds or exercising may help.
Once we get into more specialized treatments, that might include pelvic floor exercises with or without a physical therapist that's trained in that. There are non-surgical options such as a pessary. A pessary is a small plastic device that you can put in the vagina that helps hold things up. And then, there are many surgical options as well.
Warner Huh, MD: And can you just comment for me, just in general terms, what those surgical options look like for women?
Dr. Gena Dunivan: So there are surgical options that we can do, different route. So that one might be through the vagina and we use your natural tissues to help support things. And sometimes we can do another procedure where we do use a graft or a permanent material to help support the vagina.
Warner Huh, MD: Yeah. So again, I just want to kind of recapture some of what you said. I'm a little bit surprised, because you're saying up to 50% of women during their lifetime will experience some element of pelvic organ prolapse. Is that correct?
Dr. Gena Dunivan: Yes.
Warner Huh, MD: Wow. Okay. So again, I want the listeners to know that because ,again, I think this is, you know, an underrecognized problem that I think actually has multiple solutions, whether it's nonsurgical or surgical. And, you know, I think the intent of the podcast is just, again, raise simple awareness that this exists and many women are not alone. So one of the things I thought you might want to comment on, and I think some of our listeners are aware of this, is that over the last, I guess, maybe 10 to 15 years, there was widespread use of something called prosthetic mesh for these repairs, particularly for surgical repairs and that there was some controversy related to that. And I thought maybe if you could just touch upon that briefly and just share with the listeners what that controversy is.
Dr. Gena Dunivan: Yes. So there has been a lot of growth and development in this field over the last few decades. So there was a surgery that was developed to treat stress urinary incontinence, and that is the leaking when you sneeze or cough or laugh. And this new development really revolutionized how we do surgery for women that have this condition and what went from a long and complicated surgery that might involve days in the hospital as well as variable results. This new surgery that did involve placing a small piece of mesh under the urethra basically resulted in same-day procedures with great success rates.
Unfortunately, what happened is that some companies took that success and created mesh kits, which the idea was that it was large pieces of mesh that were placed in the vagina to help support it. And unfortunately, they were not studied well and they were marketed very widely, including to providers that may not have completed specialized training. And what was discovered is that when you put large pieces of mesh through the vagina, oftentimes by people that aren't necessarily as familiar with the anatomy as they should be, it resulted in a lot of complications and many women suffered.
So mesh is not good, bad, or indifferent. It's just a tool we use. And when it's used under appropriate and specific circumstances, it can be very helpful and result in great outcomes. Now, all of these "mesh kits" are no longer available. That's what you might hear when you read that the FDA recalled them. But mesh is still used in some of our procedures and this has been very well studied and is safe, especially in appropriately trained people.
Warner Huh, MD: So I want to just confirm what I'm hearing from you, which is that you're not saying that all use of mesh is necessarily bad and that there are selected times when used appropriately that prosthetic mesh is an important component for the surgical repair or pelvic organ prolapse. Is that correct?
Dr. Gena Dunivan: Yes.
Warner Huh, MD: All right. And I don't want to throw the baby out with the bath water, right? And so, you know, I think sometimes people hear mesh, "Oh, I'm going to steer clear of this," but again there's a clear need or use of mesh when appropriate.
Dr. Gena Dunivan: Yes, absolutely.
Warner Huh, MD: Okay.
Dr. Gena Dunivan: And I'd like to take this as an opportunity to pull from that example that I just explained and talk about something else that I see as evolving in our field. And that is what is being heavily marketed as vaginal rejuvenation surgery or vaginal cosmetic surgery. So this is being marketed directly to women and oftentimes women feel that this is going to help their prolapse symptoms, but it's not going to. The treatments that I described before are the well-studied treatments to help with pelvic organ prolapse.
What I often will remind my patients is that pelvic organ prolapse is a medical problem. And therefore, the insurances cover the treatment and that includes physical therapy, pessary or surgery. With these cosmetic procedures, women have to pay out-of-pocket. So often women are paying hundreds to thousands of dollars for treatments that are not well-studied and don't work necessarily for what they think are going to help the patient.
Warner Huh, MD: I guess what you're saying is that kind of buyer beware.
Dr. Gena Dunivan: Exactly. That if a provider is asking you to pay out-of-pocket for something, I would really encourage you to ask questions about why insurance doesn't cover it and what are the studies that actually support the use and the effects that it's going to have.
Warner Huh, MD: Yeah. And as I'm listening to you, it occurs to me that we probably would benefit from having a separate podcast on vaginal rejuvenation and, as a tangent to that, about its role again or absence of role in pelvic organ prolapse management. But again, just to kind of recapitulate what Dr. Dunivan is saying, is that, you know, beware, I think that the evidence is limited in this space. But more importantly, that you may be asked to pay a lot of money out-of-pocket really for a very unclear or questionable clinical benefit.
Dr. Gena Dunivan: Yes, I agree with that.
Warner Huh, MD: Okay. So, you know, one of the things I was just kind of curious about is that urogynecology, although the surgeries that they do is not new to gynecology, the profession itself is relatively new to the community. But can you just share with the listeners about what makes the Division of Urogynecology and Female Public Medicine and Reconstructive Surgery here at UAB unique when it comes to the management of these women with pelvic organ prolapse?
Dr. Gena Dunivan: I'm very proud of the division here at UAB because, as I mentioned, there are many treatment options available and women are best served by going somewhere where all of those options are fully available to them. Our team consists of providers, advanced practice providers, nurses, staff, and physical therapists that are all dedicated to providing women with pelvic floor disorders the best care possible. There is no one treatment to fit all women. Each patient that we see, we spend a lot of time individualizing their treatment plan because patients have different goals, they have different risk factors and they have different histories that affect how we decide with them what's the best treatment for them. Pelvic floor disorders are not a one-size-fits all and this allows us with all these treatment options to come up with the best treatment plan for each individual patient.
Warner Huh, MD: Yeah. So I kind of want to take that a little bit further because this is true for a lot of the gynecology services that are provided, is that it's no longer just a one single provider provides a one-size-fits-all management for women. You know, I think urogynecology and management of this problem, pelvic organ prolapse, requires a significant team-based approach. And I think that is what UAB in this department does quite well, is really looking at it from every angle and individualizing the management of these women. And so I appreciate your saying that because I think a lot of our listeners and women out there may or may not recognize that. It's not just one doctor or one physician or provider that's directing the care, but it's multiple people that have a role and impact in terms of the management of the individual woman.
Dr. Gena Dunivan: Yes, I totally agree.
Warner Huh, MD: You know, and the other thing I just want you to maybe just briefly touch upon is, you know, we did a separate podcast with Dr. Isuzu Meyer, who's one of your partners on the topic of stress urinary incontinence. And, you know, again, I think that people listening may be interested in this, is that oftentimes I've noticed that when you do these pelvic organ prolapse surgeries, you also do corrective surgeries to fix urinary incontinence or even fecal incontinence sometimes. I thought you may just wanted just to touch upon that briefly because, you know, I just want to make sure those two things are often combined at the same time.
Dr. Gena Dunivan: Yes. Pelvic floor disorders definitely travel in packs. So it may be that you have pelvic organ prolapse, so that can also affect how your bladder and your bowels work. So when a patient comes to see us, we assess for all of those to make sure that we're not just correcting one problem and ignoring another.
Warner Huh, MD: Any other closing thoughts or comments, Dr. Dunivan, that you want to share with our listeners?
Dr. Gena Dunivan: My closing thought would be that I really encourage women to talk to their providers about this. It is so often that I see a patient in the clinic that says that, "I'm so glad I finally found. Why did no one ever tell us that this field existed?" Part of it is that we are a newer field, but the other part is that there's such a stigma and shame that women carry that's associated with these pelvic floor disorders. And there's nothing to be embarrassed about. It's very common and there's a whole field that was developed to help you with these problems.
Warner Huh, MD: Yeah. That's like the perfect conclusion to this podcast, Dr. Dunivan, because that's the reason why I invited you, right? For our listeners to be aware that this is a highly common prevalent problem, but a problem that has multiple solutions and that women don't need to suffer and their quality of life doesn't need to suffer and that there's a way to manage this. And so that's really the goal for this podcast. I appreciate sharing your thoughts on this.
So again, I want to thank Dr. Dunivan, for updating us on public organ prolapse and its contemporary management. This was really a necessary and fantastic update on this topic. And again, I love driving further awareness on these various women's health issues with the community. So as always, please rate this podcast and we welcome any comments, particularly on topics that you're all interested in. And for more information on our urogynecology services or other gynecology services for that matter and expertise and other clinical services at UAB, please check out uabmedicine.org. And until next time, hope you all have a great day and we'll see you next month. Take care. Peace out.