Medical & Surgical Management of Pelvic Organ Prolapse: A Case Based Approach Originally Broadcast: June 29, 2021 at 6:00 PM EDT
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Join us to discuss practical clinical and surgical pearls in the management of women with Pelvic Organ Prolapse, including pessary placement.
Review symptoms of Pelvic Organ Prolapse
Recognize the diagnostic evaluation pathway for individualized patient care
Discuss treatment options including both conservative management and surgical interventions
Review pessary selection and placement based on clinical symptomology
Marian Acevedo-Alvarez, MD, FACOG Assistant Professor of Female Pelvic Medicine and Reconstructive Surgery Loyola University Chicago Medical Director Loyola University Medical Center Urogynecology Outpatient Clinic
Vrunda B. Desai, MD Medical Director CooperSurgical Welcome today. We're so excited to be talking to you as we celebrate pelvic organ Prolapse awareness month with this webinar medical and surgical management of pelvic organ Prolapse. A case based approached. We're doing this in collaboration with the Association of Pelvic Organ Prolapse Society. And this webinar is done with dr Marion Acevedo Alvarez. Dr Alvarez is an Assistant professor of female pelvic medicine and reconstructive surgery at Loyola University in Chicago. She is the medical director of the Loyola University Medical Center, Euro Gynecology Outpatient Clinic and is the Associate program director for the baby to I in residency. Thank you so much. Doctor? S veto Alvarez for being here today. All right well thank you so much. Doctor decide for having me. I'd like to start with my disclosures. Um I am funded by the NIH by an internal grant from Loyola and I am a speaker first, cooper surgical as well. All right, so today we're gonna talk about we're going to present six different cases. Um It's gonna be a review of the pelvic organ prolapse. Um We're gonna talk about different diagnostic evaluation pathways that can be individualized for patients. Um We'll discuss discuss different treatment options, including both conservative and surgical management. And we will review pastry selection and placement based on clinical symptoms. In terms of the six different cases, they are divided into two sections. Um The first one will talk about use of pastry, whereas the second one will talk about different surgical management. All right. So a little bit of background um pelvic organ prolapse or pelvic floor disorders such as urinary incontinence, fecal incontinence affect one in five women in the United States. The annual cost of ambulatory care in the US is almost $300 million and that is based in 2000 and 10 on data from 2010 Surgical repair. Pro last was the most common inpatient procedure performed in women older than 70 years and approximately 200,000 surgical procedures for prolapse are performed annually in the United States Patisseries and prolapse. Um in terms of pastries and prolapse, 70-90% of patients report resolution of symptoms after using pastry for a few months. And the number of American women age 65 or older will double more than 40 million by 2030 does greatly increasing the population of women at risk for pelvic organ prolapse. Um so that was a little bit of background. I wanted to start off with case number one, which talks about pelvic organ prolapse or P. O. P. So this is the 64 year old woman with stage three pelvic organ prolapse. She did not have any urinary incontinence. Um she reports feeling vaginal vault symptoms. Um she's also not interested in pursuing surgery in terms of her medical history. She has hypertension, diabetes and she has a surgical history of a police suspect. To me. All right, so how do we evaluate this patient? Um, Usually we start with a history. So it's really important to get a sense of when the patient started having symptoms which symptoms she is reporting for public organ prolapse. Epidemiological studies have shown that the most common symptom type is vaginal bulge. That's very different than having a patient that reports pelvic pressure, pelvic pain. Pelvic organ prolapse tends to not cause any pain. So, if the patient is reporting pain pressure symptoms, um, then you should start considering different ideologies for their for their symptoms. And as I mentioned before, symptoms, severity is really important. So the fact that a patient has pelvic organ prolapse does not mean that the patient need needs treatment for pelvic organ prolapse if the patient has stage three, stage four, so, relatively advanced prolapse, but there's no symptoms, then really no treatment is indicated in those cases. The next step would be physical examination. So it's really important to get a sense of the degree of prolapse are the symptoms out of proportion to what the what the exam is showing. In addition, it's really important to assess the public floor muscle tone are the absent week, normal, strong and to perform a post void residual. Now, in terms of post void residual, these could be done either with a scanned, like a bladder scan or categorized and it's really really important to get a sense of how well the patient is emptying their bladder if they have urinary symptoms and if there's also prolapse past the Hyman because when they have when patients have urinary symptoms and prolapse past the Hyman. Then we start thinking about obstructive urination, your urethral, thinking that could be caused by sister seal or advanced prolapse. And then for non your gynecologist, the famous Pop Q. So when is it important to perform the Pop Q. The benefits of Pop Q. Is that it's standardized. It's very easy for physicians to communicate gynecologist, your gynecologist to communicate about the exact pathology and that patient when a popular is performed. However, uh, they might be challenging if you're not performing them on a regular basis. I think what's really important is to determine if the if the prolapse is past the hyneman or if it is above the Hyman. Uh, most patients will develop symptoms when the prolapse is past behind men. Um, if the prolapse is above the Hyman, the symptoms tend to be less and they are less of the obstructive urination and obstructive. Keep defecation symptoms. And it's also really important to discuss with patients. What are the goals of treatment? Are the goals of treatment to have to avoid surgery? Is it important to just be active physically? Is it important for the patient to have the treatment option that is going to um improve their symptoms in a definitive way? So they don't have to come in for accessory checks, better evaluations. That's when you start considering surgery. So it's really important to discuss all of those goals of treatments with the patient. All right. And then this is an example of pop or public or again prolapse quantitative test in this case. This was done with the patient's supine and maximum strain. I think it's really important to consider that the patient is reporting bulge um and feeling tissue protruding through the through the vaginal enteritis. Um to make sure that the exam is done both supine and standing. If you're not able to see the prolapse on supine position. And the idea is that by having the patients stand, you might be able to maximize the prolapse, especially for elderly patients that have less um ability to mount a stronghold salva uh pressure than those patients, that might be worth it to perform the exam standing. So this is a slide that talks about the Pop Q. Assessment. So again, the park you is a pelvic organ prolapse quantitative assessment. It allows physicians to communicate um what the exam shows in a way that standardized and it helps monitor treatment response. Um So in this case uh this POP Q. Is done supine and maximum strain. Um I think it's important to note that if a patient reports symptoms that are not being observed with the POP Q. Especially in the elderly patients that might have a hard time mounting a strong el salva. Um It might be helpful to repeat the POP Q. With the patient standing. And that is because gravity helps bring the prolapse down. So in this case the POP Q. Shows stage three pelvic organ prolapse the positive number especially the two at the A. N. B. A. Point. Um and at sea um show that the Prolapse is at least two cm past behind then. And so ox has really helpful um app for I for um phones that helps input the POP Q. Or the exam depending on um what the physician schools are. Um and helps both for teaching and for patient education, helps put into a diagram what the what the exam is showing. So in this case on the left um this is a normal uh female anatomy without any significant prolapse. Um And as you can tell them the bottom part of that image the normal is highlighted. However, if we were to click on the assessment so the left part of that option you would see that it shows the pop you like the exam for this particular pop. Q. And in this case this patient has significant anti R. And a. Pickle prolapse. Um And that would be helpful to know as we are monitoring her treatment options. So let's talk about the different treatment options. Right? So there are surgical and nonsurgical options in terms of the nonsurgical options um We can always offer patients public for physical therapy uh And possessory pelvic floor. Physical therapy entails about 1 to 2 visits a week for about two months where the patients go and have um both external and internal X. Exercises with the physical therapist, pelvic floor. Physical therapy is a known um treatment option for both prolapse and urinary incontinence. We have good evidence that states that it works. It does not work as well for advanced stages of pelvic organ prolapse in terms of other non surgical options such as the pastry, which is a ring or a device that is inserted into the vagina and it helps support the pelvic organ prolapse so that the patient has less of those bulge symptoms. And then when we talk about surgical options, there are obliterated procedures such as the copa crisis um which features the front the anterior and posterior wall so the vagina together and it's low risk, low rate of recurrence uh but does not allow the patient to have penetrative intercourse in the future. And then we have the two types of reconstructive prolapse repair. So vaginal reconstructive prolapse repair and laparoscopy, robotic or open abdominal prolapse repairs. And we're going to talk a little bit about each of those. So in this case after talking to the patient, she opts to undergo past three treatment. All right. And something that I think is really really important is to um emphasize the roles of pastries and management of pelvic organ prolapse. Um This is a campaign from on the american Uruguayan society. It's called choose slightly and it's sort of like the 10 most important things uh decisions and patients should know and should question. And one of those number three is to not exclude pass Teresa's treatment options for pelvic organ prolapse. And so it's really important for us as physicians, especially generalist O. B. G. Y. N. Or primary care physicians to talk to patients about nonsurgical options for their prolapse. It is very low risk to attempt a possessory And in some instances it might be the only option to manage the patient's symptoms. So it's always a good idea, especially if the patient is not 100% sure if she's going to be interested in surgery or not to discuss with the patient or to even try a pastry. Um The worst thing that can happen with past three trials is that they fail and then you discuss with patient different treatment options like surgical options. So um this is the uh past refitting kit and um on the right, you can see the past refitting kit with different sizes, different shapes, different um like a lot of different options that you might be able to discuss with patients on the left. There's even more options. The goal of today is to make sure that you're not scared when you see all of these options and when you're discussing with patients of different past three options, the goal is that you feel more comfortable and you can discuss with patients um what the past three treatment options are and and what treatment uh past three fittings and pastry management means. So these are just some of the more common past three options that are that are used the rain, which is the one that is shown on the right. It's mostly used for stage one and two. Public organ Prolapse so milder degrees of public organ Prolapse the one on the left or the Gellhorn is used for more advanced public organ Prolapse stages like three and four. Um uh The way the gal horn works is that the um ring portion sort of like works as a section and that's why it is meant to be used for more advanced uh Prolapse stages, it tends to support the organs better um in terms of contra indications and mrs per company guidelines. Um There are some there are a few of them but there are some and these include pelvic infections and lacerations, patients that are non compliant. So patients that are non compliant, we should also think about patients that might have dementia or other cognitive issues. And these are patients that you might insert the pestering and might not come back to your office. And so in those cases it's really important to um to be able to counsel patients properly and confirm that they are that they are adequately following up. There have been some case reports of pastries eroding into adjacent organs if they are not properly managed. So that's noncompliant patients, especially in the pelvic organ prolapse population which tend to be older. It's really important to identify them and counsel them properly. Others are in the Montreal says pregnant patients. And in the case of the gal horn, sexually active patients. And that's just because it would not be feasible to be sexually active with the Gellhorn in place. Okay, so these are the instructions on how to place um the ring pastry with support. Um These are the instructions for use from cooper surgical. And so essentially you usually you take the pest free, they can be folded in half. I usually tell patients when I'm teaching them how to manage that. You fold the past 3.5 kind of like a taco. Um And then they are inserted through the high middle rang. The in troy is, and once they are inside the vagina they open and they sort of fall into place. Figure three shows the proper placement for the ring pastry with support. And you can tell that it is um They're quite proximal in the vaginal canal and it sits behind the pubic bone. Um I usually have patients while salva or cough after press replacement to confirm that it's not being expelled. All right. And then a few fitting tips and tricks. Um So it's really hard to know just you know, without trying a few batteries which which pastry is the correct one for your patient? Um Usually a rule of thumb, is that the general hiatus? So the opening of the vagina um is a, you know, certain centimeters three centimeters four centimeters. I usually bring that past three and the one that's smaller and bigger. So I have the patient's general hiatuses, three centimeters. I bring in a ring with support number 23 and four. And so I have a general sense of which pastry will most likely work for that patient. It is not uncommon to change the past, Resize the pastry type and again remember the ring with support they're much easier to use or easier for patients to handle. So that's usually where we start off. But if you need to place the past because the ring with support is being um is coming out than uh you can always try a gal horn or some of the other space occupying Accessories. And when the patients come in for their follow up, that's it. And you're doing a past recheck. Always important to remove the past three, inspect the side walls if there's any ulceration, if there is severe, you know, really significant um vaginal discharge, it might be a good idea to do a past three holiday. So let's keep the past three out for about 1-2 months, allowing enough time for the vaginal epithelium to hell. If the fastpass trees falling out it might be a good idea to try a larger pastry. If it is too uncomfortable you might want to try a smaller pastoring. I think the caveat here is to always assess the pelvic floor for my fashion pain. So when you're doing a bi manual um can always turn your hand. Um. Mhm. Towards the pelvic floor and feel and make sure that there's no line of fashion pain. That's one of the reasons why the pastries might not work. All right so let's change gears. And now we're talking about stress urinary in comments or S. U. I. So there's a 33 year old G. Five P. 4014 With stress urinary incontinence. It started in 2000 and seven after the last the birth of her last child. But it has been progressively worsening. She's changed her habits. Her activities of daily living and you know, the continent seems to be really bothers them. She's not interested in surgical management at this time in terms of a roby history. She's had four vaginal deliveries, one spontaneous abortion. She has no medical or surgical history, but she's very active. She works as a police officer. And the stress urinary incontinence is really limiting her ability to work. And I should mention before we talk about evaluation, um, stress urinary incontinence. This leakage of urine with coughing, laughing, sneezing. Um, the increase in intra abdominal pressure causes uh, the urethra which is not competent um to not be able to maintain the urine in the bladder. And so that's what leads to leakage appearance. So it's a structural issue which is a little bit different than the other types of urinary incontinence, like overactive bladder. Um Okay so then we have this young lady who has stress urinary incontinence. It started after her vaginal delivery and it's been getting progressively worse. How do we evaluate this patient? So again like the last patient the history is really important understanding specifically the different type of urine leakage that she has. So asking questions like is it leakage when you feel the urge and you cannot delay it? You can't make it to the bathroom. That makes you think overactive bladder, urgency urinary incontinence? Or is it leakage with activity when you run when you're trying when you're picking up your kids? Like is that what is happening? What's happening with the frequency? How many times is she avoiding on a regular day? Is she waking up at night to go to the bathroom That falls more within the overactive bladder pathway? Um diagnosis. And so it would be really important to make that distinction. Before we try it, we start evaluating or treating this patient and then the next step would be physical examination. So, um look for if you're thinking um stress urinary incontinence, is there any urethral hypermobility is conquering public organ prolapse? Um If the patient had uh like a hysterectomy, could this leakage be due to a fistula? Less likely. It wouldn't be leakage with activity only. But those are the things that you're thinking as you're examining this patient. Um and as I mentioned, you throw hypermobility, which I will show us in the next slide. Um but essentially have the patient, they are down or cough and you see how much of mobility is. So the urethra and then post void residual. So whenever patients have urinary leakage symptoms, it is a good idea and it is part of the recommended work up to perform a post void residual. Again this could be a bladder scan or it could be a catheter, prized specimen and you want to measure it within 15 to 20 minutes after the last void. Um Otherwise you might have a slightly elevated um measurement and it might not be accurate. And then your analysis the urine culture. So rule out other ideologies for urinary incontinence, such as urinary tract infections, Hugh, materia, tumors, malignancy. And whenever in this particular patient right, she's 33. Um she has stress urinary incontinence. It's really important to talk about patients family planning um and desires for future fertility. If she is interested in future fertility, that discussion needs to be had um particularly prior to surgical management. And then if if this patient in particular, she we're going to talk to her about treatment options, he's going to pick up a story. So future fertility um complicated vs. On complicated S. U. I. Those are less of an issue in this case because if they were going to put it if we were going to fit her with a pastry we could very easily remove the past three. But if you're considering doing surgery so and um more invasive procedure it would be really important to determine if the patient has complicated or uncomplicated S. U. I. Complicated issue. I patients who with any physical activity heavy leakage of urine complicated sus are the ones that might have also some urgency in bacteria. Uh nocturnal any reasons they wake up and they've already avoided in bed. So those are things that are really important to determine before performing surgery. All right then this is a quick assessment of urethral angle. So very rarely do we do the Q tip test where Q tip is inserted into the vagina, but that's how it's been traditionally described. Um So if the patient is at rest the angle of the urethra, so there's a Q. Tip and the urethra agency it based on the Black line. Um that is at 0° with if there's hypermobility there's more of a 30° or higher um um displacement of a Q. Tip. Um And if there is is less than that, then it doesn't it doesn't count as a regional hypermobility. Uh In terms of the treatment options for stress incontinence or nonsurgical and surgical options just like pelvic organ prolapse. For nonsurgical options, easy behavioral modifications, avoiding bladder irritants, time void so that the bladder empty and it's not to fall so that the symptoms are less public for physical therapy. As we have this as we have discussed in the past, It also helps with muscle pelvic floor, muscle coordination and avoidance of stress urinary incontinence symptoms, accessory, and then surgical options such as like a reasonable bulking agents, mid urethral sling placement or pubic vaginal sling. And again, as we discussed with the station, she has opted for a pastry. All right, So the past three options for stress urinary incontinence are a little bit different than the ones that we would consider for pelvic organ prolapse. Um, as you can tell them these slides, there's a rain with a knob and it's really the knob, the portion that helps support the urethra. And it's the one that helps actually treat the stress urinary incontinence. So there's a um incontinence dish with the knob, which is the first one that has shown, um and then the ring pastry with a knob, which is the one right underneath that. Um And these are meant for stress urinary incontinence with or without my mild prolapse, similar to the pelvic organ prolapse accessories. They have some contraindications such as infections and non compliant patient and dimitrios is in pregnant patients And how to insert it again. These are according to the instructions for use. The patients are folded. Um so um the figure one on the left side is the dish with a knob. Figure one a. Is a ring with a knob um and they are folded so that it's easier to insert through the vaginal um into the vaginal canal. Mhm. And so they are inserted into the vaginal canal at an angle to minimize patient discomfort. Both of these images show the providers finger um on the post your vaginal wall, pushing down to facilitate entrance with the pastry. And then, as we have described before, um the pastry fits in the more proximal vaginal canal if it's right behind the pubic bone. And in this case it's really important that that novice placed interior early so that it helps support theories about the level of the bladder neck. Okay? And this is just a summary slide with with all of the different steps for replacement. Great so now we're gonna we're gonna advance to the next level. So now we have taste three pelvic, we're gonna pull ups and stress incontinence. So this patient is going to have both both of those conditions. There's a 64 year old with stage three pelvic organ prolapse. She's not interested in pursuing surgery. You might remember her from the first one. But this time this patient does report stress urinary incontinence, Medical history, hypertension, diabetes and a history of an app. And next to me, so very similar to case one. But this time with urinary incontinence. So again we're evaluated the patient history assessment of symptoms severity. Really important now because she has a prolapse and the urinary incontinence symptoms, we have both that post void residual becomes even more important. Um so it's really important to to confirm that she is able to empty the bladder and that some of her stress symptoms are not related to urinary retention. And again, discussing goals of treatment, um surgical, nonsurgical options and even if it's surgical, what is most important for her. Okay, so again, same patient? S case number one, she has pelvic organ prolapse this time. Um She has stage three as the first one. And now when we do the PBR the post void residual, the PBR is shockingly 300 CCs. You had her cough during your exam and her cause stress test is positive. Um so again, stage three public organ prolapse, she is in retention. So even though let's say that this patient came in and she was not symptomatic of her vaginal vault symptoms With a PVR of 300. Now we start thinking that there's probably something that needs to be done. Um, just long term you're in, your attention will have implications for upper tract. So her kidneys, et cetera and the cough stresses is positive. So there's certainly some structural deficiencies to her you lisa. So this patient opts for possessory option. She has both publicly and collapse and stressing common. So it's really important to merge those two concepts so much the concepts from case one and case two. And make sure that we're choosing the correct pastry in this case. So as you can remember from case one, we have the ranks with support. Those will help with the public organ prolapse component of her symptoms. But now it's really important to also also have used batteries that have a knob so that that knob explaining with the arrows will help manage the stress urinary incontinence component. Okay, now we're going to talk a little bit about different pastry troubleshooting. Um, and things that we can do when patients have tried a pastry and they're not really happy with their pastry, common symptoms. After past refitting patient is bulging around the pastry, the pastries get expelled. There's pain with the pastry, the stress incontinence is working with the pastry or there's alterations. So we're going to go 1x1. So when the patient's bald around the pastry, it is one of two reasons. Either the patient is the prolapse is advancing or we don't have a pastry that is large enough to manage her symptoms. So for these cases we want to consider it. A larger pastry of the same type would work. Or we might consider just consider different types ring with support. Usually as I mentioned at the beginning, these are for stage one or two prolapse, they are for milder prolapse. If the patient is bulging around those, then consider a gal horn or some of the space occupying pastries like a donut or acute. If the pastry is being expelled again, the most common causes for unsuccessful pest refitting lower. So they are younger, they have a higher B. M. I. Or maybe they have a large general hiatus, so the opening of the vagina, if it is greater than six centimeters, the pelvic floor muscles, which are usually the ones that hold the pedestrian place and support it are too um stretched out and so they won't be able to hold the pedestrian place or patients that have had radiation prior surgery um and have a short diagonal length, so anything less than six centimeters 45 centimeter length vagina. It's really hard to find the correct pastry and it's possible that those patients might not be pastorate candidates. That is very rare. Less than 25% of patients are not able to be fitted correctly with a pastry and then pain with accessory that is also very common. Some of the more common causes for pain with certain with pastry, either the pastry is too large or as I mentioned before, the patient might have my own fashionable pain of the pelvic floor. So the pelvis is sort of like a bowl right with the sides being the pubic bone and the floor is made out of muscle live eight or a nine and some other muscles. And sometimes those get really spat. They have spasms and they become really painful. And in those cases of pastries will exacerbate that chronic underlying pain and that might be a reason not to place accessory on that piece. So an occasion. The stress urinary incontinence might be worsened by the pastry in this case, as I have mentioned initially, um it is possible that there is a cult stressing content. So if the prolapse is to is advanced there is um prolapse of the anterior vaginal wall. Qingqing of the urethra, it might mask some underlying stress incontinence. Once the battery is fitted, the prolapse is reduced, then the stress incontinence is unmasked. And so in those cases if there's a pastry that's placed on the patient has stress incontinence, it might be a good idea to replace the past three with one of those pastries with a knob. And that way the stress component is also addressed um confirmed that the that the pastry being used as a knob. Consider trying a larger pastry. But it is common for these patients to for the stress incontinence to be a common indication to proceed with surgery. And the reason is that you're you're taking care of one issue like the vaginal vault symptoms and then unmasking a new one like urinary incontinence and not usually triggers surgical management and finally alterations. So it's very common to have alterations. It's possible that it might be because the pastor is too large for a lot of these patients that are postmenopausal. It's always a good idea to start them on vaginal estrogen at the same time of pest refitting. And that is because it helps protect the vagina. Um There's very good data that vaginal estrogen helps protect against alterations and some of the complications of pastries. It is possible that if the alteration is too large that the patient might need a pastry holiday, so that's about 2 to 4 weeks without the past three. If there is a lot of graduation to ensure that is encountered, it might be a good idea to and and if it hasn't resolved with a past three holiday might be a good idea to cauterize it with silver nitrate because the body, it's hard for the body to um to absorb the the congratulations tissue. Without Kateri, however, is that the alterations were persistent or the regulation tissue is persistent. It's very important to biopsy that site because there could be an underlying malignancy. Um And again, it's one of the more common causes for discontinuation and needing surgery. Um having alterations leading luxury holidays frequently often often triggers the next step which would be surgery. But what's really important is to remember, you can always refer these patients you're friendly, you're a gynecologist or female urologist. Um We usually have um carts of factories in our office and um we have more of the supplies needed to refit patients or counsel them about different treatment options. Alright, Case number four SAn Procopio vaccine. So this is our same patient, the one who had prolapse and she developed stress incontinence. And now she's 64. She has stage three pelvic organ prolapse. She's also having stress urinary incontinence with with you know when she's exercising and she has been successfully managed with a Gellhorn pastry for over three years. However, she is sexually active um and she is now interested in pursuing surgery. So she has a medical history of hypertension, diabetes, surgical history of college mastectomy. And she's a marathon runner. So this is an important part of her social history. When we are selecting surgical options for this patient. Um We would want okay an option that is that is has the lowest risk of recurrence. Because the marathon runner has a high risk of developing prolapse even after surgical management. And this is our Pop Q. Assessment. She has teached three pelvic organ prolapse, maximum strain. You can see the examine the right side. But what's different now is that we're gonna be talking about the different surgical options. So the same patient, we perform a proper assessment. She has stage three public organ prolapse this time the PBR is still 300. But when we do costs trust test it is negative. So we won't address, we will counsel her about different treatment options. And it is um we will discuss with her um if the stress urinary incontinence needs to be addressed during the same surgical procedure. Yeah. So sick Prokopec see um in this case, almost all of the professional societies recommend the pop QB performed prior to surgery. And the reason is there's baseline examination, as I mentioned, it standardized, it's reliable. And what's going to be really important is that it identifies and characterizes the different types of recurrences and it will help us um plan treatment if there is indeed a recurrence. And as I mentioned in the previous slide, it's really important to consider a cult stress incontinence When we have in here or a pickle prolapse. This may lead to your reasonable qingqing. It's important to perform a cough stress test that 300 ccs are higher and the cost trust us. So you ask the patient to cough with a full bladder. This is performed with native neutral and reduce positions. So have our cough. With the prolapse. Yeah it's maximum point neutral and with the prolapse that are reduced positions. So you're trying to mimic what the body is going to be doing after surgery. About 60% of women with a positive test will have post operative stress incontinence. So as we had shown before, there are different treatment options. We already went through our nonsurgical treatment options. And after discussing with this patient, she actually select a surgical option which is the lab risk opic robotic open abdominal reconstructive repair. So um this patient of the sacred cotopaxi, these surgeries have a very high success rate. Their same day surgeries. Often patients are discharged on the day of surgery. Then for these procedures the mess is attached on the anterior posterior vaginal wall so the anterior longitudinal ligament about the level of S. One. So the bladder is dissected out from the anterior vaginal long the rectum is dissected off from the posterior vaginal wall. The mesh is attached in a wide configuration upside down y with the anterior um leave for the mash attached to the anterior vaginal wall, poster to the post your vaginal wall, and then the stem of the mash is attached to the anterior longitudinal ligament. There's usually a 6-8 week total recovery period. And there are some, you know, operative risks bleeding infection, paying damage to the adjacent organs. Whenever we're doing vaginal surgery, we need to discuss the risk of the no. This baronial with patients, there's also the risk of mash exposure. These meshes are permanent materials. Um the newer lightweight mesh is have a very low risk, lower risk of recurrence in comparison to the older generations. And so the risk of recurrence. Now, the risk of mesh exposure now is quoted about less than 1% case number five sling. So this is similar to her case. Number two. The young person who had was 36 have stress incontinence after the birth of her last baby. Um She tried to pass three. It didn't work, it got progressively were. She has she's healthy, no medical, most surgical history. Um But she's still very active. She works as a police officer and now she's done now she opts to proceed with surgical management. And interestingly she is not interested in future fertility. She is not gonna is planning on pest management. And as we mentioned, she has used a pastry successfully for many years. Yeah. And now we discuss the same options with this patient. This time she has opted to undergo a mid urethral sling, which is the preferred procedure for surgical management of stress in comments. So retro pubic slings are more than 90% effective. They are same day surgery take about 30 to 45 minutes. Patients recover very well in 3 to 10 days and the risks are relatively low. They're considered a minor procedure. Um, but the risks are like for psycho cotopaxi, there's a risk of mesh exposure and there's a risk of urinary retention. So usually for the military throw slings, we discussed with patients, especially on the day of surgery, there's about a 30 40% risk of retention that they wouldn't have to go home with a foley catheter and then returned to the office for a repeat boy trial And finally, case # six, combining both prolapse and stress incontinence. And this is the case of a laparoscopic hysterectomy. So there's a young patient that has abnormal uterine bleeding and unexplained and she really doesn't report any symptoms of pelvic organ prolapse. But you do notice some dissent that it is above the level of the Hyman her leading edges, that negative one, so just one centimeter above the hyneman. Um She has failed medical management for abnormal uterine bleeding. She maybe feels a little bit of a bulge, but only when she's pushing really hard. And she's very interested in pursuing surgery in terms of her medical history. She's over white, she said to me babies, um no surgical history. And um and she works as a nurse in L. And D. So she's very active. So again we discussed the different treatment options. She is certainly having a hysterectomy. So that's and our plan is to perform it laparoscopically. She has a no normal mobile uterus with minimal prolapse at the time of our hysterectomy, which we're gonna do a lot of risk optically. We're gonna do some also native tissue prolapse repair. And so when we have patients that have even mild prolapse, it's really important to address the apex. So ethical suspension is recommended with a hysterectomy for a pickle prolapse. This is an effective and a low risk surgery and laparoscopic native tissue repairs do not use mash or raft materials. This is a utero sacral ligament suspension which could be done at the time of a laparoscopic hysterectomy. In this case it's really important to tag the eucharistic roles at the time of the hysterectomy. Now be mindful that the more distal you are in the Euro signals, the closer you are going to be to the ureter. And this procedure has about a 1% risk of your federal injury. So it is best to um perform leader cycle suspension and take the futures of the Euro. Sacral ligament as proximal as possible, as close to the sacrum as possible. And there are one or two stitches on each side of the universe, take roles and then those are attached to the vaginal cuff. And that will provide proper a pickle suspension for a patient. It's a very easy procedure to do at the time of hysterectomy. However, it's really important to perform a cyst Oscar p to ensure that there is property. General Patton see at the end of the surgery and it's just because it's very close to the your orders. Well, thanks so much. Doctor asked Tito Alvarez, that was really, really insightful and really informative. Our first question actually is about pet stories in general, you know, as residents and as trainees, we get very minimal training often in pestering care. And when we look at that big box of all those pestering fitting, you know, it's sometimes very overwhelming. You know when we start clinical practice, what are some tips and tricks that you might be able to give some of us or even some of us that have been practicing for a really long time on how to look at these accessories and not be completely overwhelmed as we look at them for our patients because we know our patients should use them. But sometimes it can be completely overwhelming to try to move in that direction. Sometimes that first step of getting to feel comfortable with accessories. Yeah, for sure. And I think it's a very normal feeling so do not despair. Um A couple of things that I think are really helpful is when you're examining the patient get a sense of that general hiatus. So if you have a pop acoustic or a ruler or something that can help you measure. Um and it's usually between the mid urethra to the posterior for shit and that I'll give you that measurement and then when you walk out of the room, if the peach always it's always a good idea to start with. The ring with support, it's just an easier password to use. So as as long as um like that would be a good general rule of thumb bring in at least three rings with support that are one sentence that are smaller, same size and bigger than that general hiatus. And that will just be a good starting point. If the ring with support doesn't work, go to the gal horns um and do the same. Bring in several sizes. It's a lot of trial and error until both you feel more comfortable and you get a sense and be able to predict which possibly will be best for that particular patient. Thanks. I think those are some really great sets because it can be so overwhelming when you think about which passed. Sorry, should I start bringing in like which one do we even start with in the room? So I think that's that's really helpful. You know? Another key thing that we often get questions about is well how do I ask the patient if they have stress urinary incontinence? Are there any good questionnaires out there that you use to kind of in your screening process for patients? You know we don't have a lot of time with all of our patients. But as we're moving toward more kind of sitting in the waiting room again, how do we ask these questions to get a good sense of what's going on with the patient without having to like fill out our own checkboxes for sure. I personally really enjoy the mess up questionnaire. I mean there's many questionnaires that have been validated for urinary incontinence in our practice. All patients get both messa and the PFD I. Or pelvic floor dysfunction inventory that you know addresses urinary public or in prolapse and fecal incontinence. Um So those are some options. Um The reason why I like the message questioner in particular is that it very clearly has two sections stress incontinence and overactive bladder urgency incontinence. So it's very easy in a busy clinical practice to just visually look at those two sections. And if patients respond all the time to the stress incontinence and never to the O. A. B. Then you're done. You have your diagnosis. Yeah, that's really helpful. Um This other question is really around as a generalist or even as a mid level provider. How do I know when it's really appropriate to send over to your own gynecologist? I don't want to over um refer. But I do feel that there are some questions that I need some help with. Do you have any guidelines on when to refer? Yeah, I think if it is um, you know, all those uncomplicated patients, patients that have sister seal or stage 23 pro labs that are emptying their bladder, don't have any obstructive symptoms. No obstructive urination, obstructive defecation, um that you are, you feel comfortable counseling them. You can't even say, hey listen, there are surgical options or different surgical options. And there are these nonsurgical options. All those first line referrals to pelvic floor physical therapy. I think that could very easily be done by a generalist. I think some of those easier past three fittings to could be our perfect generalists or mid level provider uh level. But I think once you've tried to three pass reason they're not working or accessory is fitted and the patient has weird pain and you can't really distinguish why she's having pain or the pastries. You started getting complications with the press race. I think that's time when you can start thinking about referral. Yeah. So it doesn't seem like there's a specific time per say that you know, keep the patient for six months, try to do conservative therapy, etcetera and then go ahead and refer out. It's really based more on the clinical kind of just stopped that you have the whole nation clinical and patient symptoms because often you'll have patients that will come in and say, I don't don't even talk to me about the past three. I definitely want surgery. I want mesh. I want what's most, you know, lasts the longest. So those patients could be referred. But if you have a patient that is unsure, that needs just a little bit more time to think about it. And if you have pastors because some offices won't have pastries or won't have a full array of options than any of those times, it would be reasonable to refer. Well, thank you again. We are so excited to have you here for pelvic Organ Prolapse awareness month. I think there's a lot of awareness that needs to be done for both patients and for clinicians on this really important topic. So we really appreciate you taking the time to join us as we help educate our colleagues in this area of pelvic organ Prolapse have a great day.