BackTable / Urology / Podcast / Episode #66
Management of Female Stress Incontinence and Pelvic Organ Prolapse
with Dr. Amy Park
In this cross-specialty episode of BackTable OBGYN, Dr. Amy Park chats with Dr. Jose Silva, a board certified urologist and co-host of BackTable Urology, about the workup, counseling, and management of urinary incontinence and pelvic organ prolapse.
BackTable, LLC (Producer). (2022, November 17). Ep. 66 – Management of Female Stress Incontinence and Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
The co-hosts begin by briefly discussing the workup for pelvic organ prolapse (POP). Dr. Park identifies common symptoms of prolapse and special exams (e.g. Pelvic Organ Prolapse Quantification System or POP-Q and urodynamics) that may be utilized for initial evaluation. She then explains the clinical indications for treatment of isolated POP, in addition to POP with concomitant urinary incontinence.
Drs. Park and Silva then transitioned to cover the management of urinary incontinence. The two co-hosts reveal the benefits of pelvic floor physical therapy and other conservative management options, such as core-centric exercises and weight loss. In length, they elaborate on the benefits and takeaways of using sling procedures versus urethral bulking agents (e.g. Bulkamid). When discussing these topics, the co-hosts bring to light the possible differences in approach between Urogynecologists and Urologists. In regard to urethral bulking agents for treatment of urinary incontinence, Drs. Park and Silva highlight the potential role for stem cell injections. In addition, Dr. Park provides a tip to maximize patient comfort during in-office periurethral injections for urethral bulking. When focusing on sling procedures, Dr. Park highlights her preferred approach and encourages listeners to become proficient in the approach of their choosing.
Lastly, they describe their approaches to treatment of stress urinary incontinence. In their discussion, Drs. Park and Silva consider factors such as patient age, desire for future fertility, and pregnancy. When wrapping up the episode, Dr. Park emphasizes the importance of patient counseling when it comes to management of these conditions, as well as practicing shared decision making to determine the best next steps for her patients.
Nager CW, et al. Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations. Contemp Clin Trials. 2009 Nov;30(6):531-9. doi: 10.1016/j.cct.2009.07.001. Epub 2009 Jul 25. PMID: 19635587; PMCID: PMC3057197.
Erin A. Brennand, Shunaha Kim-Fine. A randomized clinical trial of how to best position retropubic slings for stress urinary incontinence: Development of a study protocol for the mid-urethral sling tensioning (MUST) trial, Contemporary Clinical Trials Communications, Volume 3, 2016, Pages 60-64, ISSN 2451-8654, https://doi.org/10.1016/j.conctc.2016.04.004.
M. Abdel-Fattah, D. Cooper, T. Davidson, M. Kilonzo, M. Hossain, D. Boyers, et al. Single-Incision Mini-Slings for Stress Urinary Incontinence in Women New England Journal of Medicine 2022 Vol. 386 Issue 13 Pages 1230-1243. DOI: 10.1056/NEJMoa2111815 https://doi.org/10.1056/NEJMoa2111815.
Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar;4(1):75-81. Epub 2011 Feb 25. PMID: 21505577; PMCID: PMC3056425.
[Amy Park MD]
My approach is to take a diamond from the top and then just measure with Allis’s, make sure that it goes up to the sacrospinous ligament, and then shorten the vagina to where it doesn't just right on the sacrospinous ligament because I think it's the length that's very important there. For the predominant anterior apical prolapse, I prefer laparoscopic sacrocolpopexy.
That being said, I'll steer the patients towards the vaginal approach if they've had a lot of abdominal surgeries, they have a large hernia repair with mesh, history of small bowel obstruction, contraindications to steep trendelenburg like a severe pulmonary disease, contraindications to mesh like wound healing issues or significant comorbidities that preclude longer OR times associated with sacrocolpopexy.
I usually counsel patients that prolapse repairs are like any other reconstructive surgery in the body like an ACL tear or facelift or knee, hip replacements. The natural history of the disease is that the connective tissue will weaken. Therefore, I usually reserve laparoscopic sacrocolpopexy for those patients who are post-hysterectomy with anterior apical prolapse who have had a recurrence or want the most durable repair. I do perform primary sacrocolpopexy with concomitant hysterectomy or sacrohysteropexy in those patients who are young, like less than 40, who desire the most durable repair. But that's not my usual go-to.
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