2025 Urogynecology for the Advanced Practice Provider-Counseling on Pelvic Floor Disorders: Simplifying and Streamlining a Complex Discussion

Counseling on Pelvic Floor Disorders: Simplifying and Streamlining a Complex Discussion

Video Transcription

is going to be Dr. Hickman kind of talking about counseling and how to pull it all together.  Hi, everyone. This is one of my favorite lectures that I give. For some of you that were here last year, you have heard this before,  but I think it's really important to bring it together. I also tried to zhuzh it up a little bit this year too, so.  I've been a research collaborator with LiveLabs, but the relationship has ended.  All right, so the objectives, I'm gonna review the strategies for explaining the diagnosis of urinary incontinence and prolapse in a way that patients can understand.  I wanna discuss patient-centered counseling on managing these conditions so that you can really feel like you're getting shared decision-making  instead of staring at like a blank face because you've totally lost the patient. And then to just highlight some patient-friendly  educational adjuncts that can supplement your counseling.  So, my general thoughts. Keep things simple and elaborate as needed. Efficiency is key. There can be lots to cover. I think a good little trick is if you have an Apple Watch  or a smartwatch, set the timer. You know, when you go in to counsel your patient, give yourself 10 minutes if you have that. I know that's a lot of time, but there's a lot to cover.  And then, you know, that can kind of keep you on track in the beginning when you're getting your spiel together. Tailor to your audience and their health literacy, right?  If you're talking to a healthcare worker, you may be able to talk about things differently than if you're talking to someone who has no healthcare experience.  However, I also will often tell my healthcare workers that I wouldn't wanna go to a neurosurgeon and have them talk to me like I know about brain surgery.  So, you know, you also kinda wanna just gauge what their level of education is and how they want you to talk to them.  I think a picture is truly worth a thousand words, and so are analogies that can make it so much simpler for patients to understand. My way is not the best way,  and your counseling will continue to evolve. But I hope I'll teach you a couple things that you can implement in your spiel to make your life a little easier with your patients.  So first, let's talk about prolapse, and I just wanna have a quick disclaimer here. I trained with Dr. Probst, and so some of the things that I say  she's already mentioned in her talk, so I won't belabor the point too much, but she taught me a lot of what I know. So, you know, you've heard this today.  What is the pelvic floor, and why is it important? It's because it provides support. Keep it simple. What is prolapse? It's like a hernia.  Most people have some experience with a hernia, whether that's abdominal, they know a loved one that's had a hernia repair, so I think that's a great kind of way to explain it.  What's involved? I use the terminology front, top, and back walls of the vagina just to keep it simple for patients, and people can understand front, top, and back.  And then putting it together, I love the Oggs PopQ tool. I have it on my phone. I sit down with a patient, and, you know, especially during the exam, if I have a trainee with me  and we're calling out numbers in the room, I tell the patients, these numbers are gonna mean nothing to you, but I can plug those numbers into an app  and show you a diagram of what your prolapse looks like,  and people are like, okay, cool, and a lot of people will say, can I take a picture and show normal and abnormal to my partner, my family member? They really appreciate it.  So, you know, you start with the normal. You orient them to your anatomy, so I always say, you know, this is a view if we split you down the middle and look at you from the side.  In the front, you have your pubic bone. I point to my pubic bone. Behind that sits your bladder, the urethra, the tube you pee through, your uterus and cervix,  if they have one, obviously. You can remove that in the app if they're post-hysterectomy.  The vagina, rectum, anal opening, and tailbone, and then I point out the front, top, and back walls of the vagina and say these are the areas  that individuals can typically have prolapse, and, you know, you already know what their exam is, but oftentimes, you know, for patients who have multi-compartment prolapse,  which is most of our patients, I just warn them that that's actually the most common thing that you have a little bit in all three areas, because some patients will think,  oh, gosh, I have it everywhere, this is really bad. Well, no, it's actually really, you know, pretty normal for what we see, and then I show them their exam.  So as far as management goes, I start with the basics. Prolapse is a quality of life condition. It won't shorten your life or increase your risk of cancer.  I say this to every single patient, and you can sometimes, for some people, think they, you know, you can immediately see them, like, breathe a sigh of relief,  that they know that nothing really bad is going on, and then this is where you can take your patient-centered approach. What's bothering her and how much?  I always tell my patients who don't have a lot of bother, it's hard to make no bother better.  What's their age? What's their overall health and physical activity? Are they doing any occupational or recreational heavy lifting? You're gonna think about someone differently  who's, you know, someone's a sedentary 85-year-old versus, you know, a 60-year-old who's going to Orange Theory three times a week. What's their surgical history?  What's their desire for coitus in the future? Do they have any pain with coitus at baseline? Or pelvic floor, you know, discomfort or pain? How do they feel about their uterus?  How do they feel about MASH? And what are their overall goals of care? And you're gonna see this multiple times in the presentation today.  So, a few words on MASH, because everybody's heard the patient say, well, I don't want that bad MASH, and so if you have your little spiel  that you're ready to say about MASH, it'll help you. So, we use a lightweight polypropylene MASH for prolapse and incontinence. Polypropylene has been used for a very long time,  since the 1970s in surgical subspecialties. In 2019, the FDA put a stop on manufacturing for MASH placed through the vagina to fix prolapse.  The MASH that we use for sacral colpexy and slings is safe with a low risk of exposure and considered the gold standard for post-hysterectomy prolapse  and stress incontinence, respectively. And sometimes patients, just with that, feel very satisfied with that response. The other thing I also say is,  it's inert, you don't reject it, we have data that says it doesn't increase your risk of cancer, you're not gonna have an immune response to it or anything like that.  As far as prolapse management, I tell patients it ranges from expectant management to surgery, and sometimes it's helpful to stop there and take a pause.  Because sometimes patients kind of already know what they want, and I'm not saying you shouldn't tell them all the options, but it's also helpful  to fast-track the discussion if they come knowing they don't wanna do anything about their prolapse and they were just on a fact-finding mission  versus they're ready to have it fixed.  As far as conservative options, expectant management, home pelvic floor muscle exercises, structured pelvic floor physical therapy, a pessary,  and keeping in mind, who's gonna manage that pessary? Some patients you know maybe wouldn't be able to, and are they sexually active?  And that can kind of help with the pessary discussion too.  As far as the surgical options, like Dr. Probst was saying, there are two categories, reconstructive and obliterative. Reconstructive with or without a hysterectomy  is done through the vagina for a native tissue repair, and that, I say, restores normal anatomy using stitches in your own tissue.  Abdominal, which is our mesh-augmented prolapse repair with or without a hysterectomy, I tell patients that mesh placed on the vagina  acts like a scaffold or like a trellis in your garden for tissue ingrowth, and then it's attached to a tough ligament on the tailbone,  almost acting like a suspender to hold the vagina up so it doesn't fall back down.  Obliterative surgery, I tell them, involves sewing the vaginal walls to each other to close the vaginal canal, but that your external anatomy remains the same  with just a small vaginal opening and a short vaginal canal. So one of our nurse practitioners always used to tell patients, they could still have outer course,  they just can't have inner course anymore.  We have these diagrams actually hanging on the wall in our office, and it's amazing, between when you come in and see the patient, you'll see them standing looking at the wall.  Once you've told them what's going on, they want to point and know what their anatomy looks like. So these are from yourpelvicfloor.org, and we have full-size posters,  and they're really helpful for counseling.  I think these kind of quick stats for when you're counseling can be really helpful. So if you expectantly manage a patient,  nearly 80% will have no change in prolapse over 16 months. So patients will say, well, I'm a stage three, is it just gonna continue to get worse and everything's gonna fall out?  And you can reassure them that that's most likely not the case.  For pessaries, nearly 90% of women can be successfully fit, and on average, it can take two visits to get a good fit. So just kind of setting the stage  that we may leave today and feel like we really got you a good fit, and you may end up coming back because it's either uncomfortable or it falls out.  For pelvic floor muscle exercises in PT, what I tell patients is it can decrease bother and improve sexual function based on research studies that are published,  and that it's best for stage one and two. But if you have someone who has stage four prolapse, sending them to PT is not gonna make their prolapse go away.  For vaginal native tissue, retreatment using a pessary or surgery at five years is about 10%. Sacral colopexy is more durable, with a retreatment rate closer to 5%,  and mesh exposure is less than 5%. And obliterative has the highest success rate, and low regret in properly selected patients.  Okay, so stress incontinence. So what is stress incontinence? It's the involuntary leakage of urine with physical exertion or cough and sneeze. And why does that happen?  You know, weakening of the components that keep urine in the bladder. Is it the supports underneath the urethra? Is it the sphincter? Is it a little bit of everything?  But basically, the urethra can't withstand the forces that are coming on the bladder, and so urine leaks out the path of least resistance.  And again, patient-centered counseling here is key. So, how much bother does she have, and when does it happen? How old is she? What is her overall health and physical activity?  Again, is she doing a lot of occupational or recreational heavy lifting? What's her surgical history? What's her feelings about mesh? What has she tried,  and what are her overall goals of care?  Management options, again, range from expectant to surgery. You could try conservative things like behavioral modifications, weight loss.  We've talked about that multiple times already today.  Pessary, you know, we had the ATLAS trial, which was a PFDN study that showed that pessary did not work better than behavioral therapies or combined behavioral and pessary.  Vaginal estrogen, you know, you could give it to postmenopausal patients, postpartum patients, patients who are on low OCPs.  Knowing that there are estrogen receptors in the urethra, and perhaps that will help with some of the coaptation and kind of thickening of the urethral mucosa  certainly won't hurt anything.  So, as far as those conservative options, you know, pelvic floor muscle exercises and PT are really first line for SUI.  Home pelvic floor muscle strengthening devices, some are actually covered by insurance. There are disposable vaginal inserts  that you can buy in the pharmacy, like what's shown here. And then there are pessaries, some that are in office, and then there are now some over-the-counter pessary options too.  As far as surgical options, understanding if your collaborators are doing them in the office versus the OR.  And the reason we do them in the OR is for reimbursement purposes only.  The success rate, I tell patients, is about 60 to 70%, 85% of people are still satisfied at one year, and the retreatment timeline really kind of is variable.  But I tell patients it's plumping the urethra kind of like lip filler, and most people are familiar with lip filler. And it increases the resistance  to make it harder for you to leak. The sling has a higher success rate, 80 to 90%, for significantly improved or dry with a very low reoperation rate, low mesh exposure,  and low risk of needing to loosen the sling. And I also tell patients, we have 17 year data on slings, so this is not a new treatment,  and the efficacy doesn't significantly diminish once you get that far out. So basically, it's like a hammock supporting the urethra.  As far as the surgical options, birches, which maybe you would think about if the patient is already having a concomitant abdominal surgery,  although I would argue a sling only takes 30 minutes, and you can certainly go down to the vagina, you might have to for a posterior repair anyway, or a fascial sling.  They have similar success rates to sling, but they're often reserved for specific settings. And so really, understanding what your collaborators offer  and do you really wanna discuss these things with your garden variety patient? Maybe not, but like I said, it's important to know what your providers offer.  As far as overactive bladder goes and urgency incontinence, so what is OAB and urge incontinence? It's a syndrome of frequency and urgency to void with or without incontinence,  and why does it happen? The bladder muscle is squeezing when it's not supposed to. It can obviously be more complex than that, we know that, but this is kinda out of the scope  for how you're gonna counsel your patients. And again, patient-centered counseling is key here.  So how much bother do they have? What are their intake and output habits during the day and at night?  That includes obviously what they're drinking, how long they can go between trips to the bathroom. That's usually what I ask patients,  because if you ask patients how many times they void a day, most people are like, I don't really know. But usually people can say,  I'm voiding every 30 minutes, I'm voiding once an hour. I drove here and I had to stop twice, and it was a two-hour drive, and you can kind of figure it out that way.  Their age, their overall health, their medical and surgical history, what she has tried, and her overall goals of care.  So again, management ranges from expectant to surgery. You're seeing some trends here. It's a process, and I tell patients that. We can't expect that everything is gonna be perfect  by just starting a pill. So I like to give them the whole menu from the first visit. That way we don't lose them because they try a medication,  they have side effects, and they think, well, I'm just gonna live with this.  And so conservative options, you've heard some of this in the earlier lectures today. Bladder training, urge suppression techniques, avoiding bladder irritants,  which totally can be more trial and error. Like people were saying, you don't need to tell them they can never have Diet Coke again, but maybe don't have six Diet Cokes a day.  Fluid management, cutting back fluids a couple hours before bedtime if they're dealing with nocturia.  Avoiding constipation, weight loss, timing of meds, including the diuretics like we were discussing, and then other options, pelvic floor muscle exercises and PT.  Most of you, I hope, would have some sort of handout that you can give patients on kind of all the behavioral modifications. I actually took this from Dr. Propst.  I have hyperlinks to all of the Voices for PFD handouts for patients, so that way you can just drop it in. And most people are pretty facile with MyChart.  It also saves you having to rummage through a file cabinet to get a whole stack of papers for your patients.  With medication, I like to manage their expectations from the outset. I say there are two general classes, the anticholinergic, block bladder muscle contractions,  the beta-3s, relax the bladder muscle.  You can choose these based on age. So as we were talking about earlier, avoiding anticholinergics in older patients,  what their comorbid conditions are, what medications they're on, labs, side effect profiles, and then short interval follow-ups are key here.  As far as third-line therapies go, I say that PTNS is like acupuncture hooked up to a TENS unit. Weekly visits time, 12 weeks, and then three to four week touch-ups, potentially,  depending on how the patient's doing. Sacral nerve stimulation is like a bladder pacemaker. I tell patients there are two steps and you get to test drive it before you buy it.  That way we know if it's actually working for you. And if your collaborator does PNEs, peripheral nerve evaluations, that's the first step being done in the office,  which is kind of nice because then a patient only needs to go to the OR one time. So knowing if they offer that. And also, if you're counseling patients about that,  you might want to get a sense of do they think they would be able to tolerate a PNE in the office and are they good candidates? So someone who has a lot of adiposity  and it might be difficult to feel the bony landmarks might not be your best PNE patient. Someone who has a lot of anxiety about procedures or fear of needles or poor pain tolerance,  probably not a good PNE patient. But you can usually gauge that by just asking the patient how they feel about those things.  And then onabotulinum toxin, I say it's like the Botox we use for wrinkles. It's an office procedure with no downtime. It lasts anywhere from four, five, out to even 12 plus months.  And then the elephant in the room with Botox, I often think is the 5% cath rate with 100 units. And so I have had patients that say 5% I'm out, I won't do it, you know?  So it's just important before you go on a long discussion about risks and benefits of Botox to understand how they feel about that.  Again, some quick stats. So behavioral is the first line therapy per ogs. A 25% reduction in fluid intake can improve frequency and urgency. Over 50% reduction in UI episodes  can occur with bladder training. But it's really hard, right? It's like potty training. And so, especially patients who are very frequent,  you're telling them they can't pee before 30 minutes. They need to resist it as much as possible. And then they're slowly increasing the interval and it takes a lot of work.  But it can be helpful in someone who especially is motivated and wants to avoid medication.  Pelvic floor PT can reduce symptoms pretty significantly, 50% to 80%. Anticholinergics are going to reduce your urge leaks by about two and frequency by about two.  About a 40% to 50% improvement is typically seen. Only 10% will be dry. So if patients, that's their goal, you might want to just set the stage there  that that's probably not realistic.  60% will have some dry mouth. And less than 50%, unfortunately, will ever refill their medication, which is why that short interval follow-up I think is really key,  so that you can keep kind of moving forward through the algorithm and find something that works with them. I also think it can be helpful as you're discussing with patients  to just highlight some strategies like we talked about earlier. If you have constipation, add this. If you have dry eyes, try this. If you have dry mouth, try this.  So that way they feel like they're equipped with some strategies.  And then beta-3s, they don't work better. They just have a more favorable side effect profile. So sometimes patients, if you really are kind of selling them your metric  and then they call and say it was really expensive, they feel disappointed because they feel like they're getting the inferior treatment, but that's actually not the case.  For PTNS, similar efficacy to meds, but no medication side effects. For S&M, 80% achieved continence or greater than 50% improvement in their main symptoms.  The revision rate is anywhere from three to 16%. Infection is pretty low at less than 5%. The batteries now last 10 to 15 years and the leads are MRI compatible  and they can switch it to MRI mode, which you guys all probably know.  And then on a botulinum toxin, similar effectiveness to S&M, 5% cath rate. UTIs can range anywhere from 20 to 40%.  I added some other kind of special populations. So for mixed incontinence, I always try to have them prioritize what treatment bothers them more first.  So I say, if I could only treat one, which one would you want me to target first?  And sometimes what happens more frequently may not be the most bothersome. So if they only have drops when they sneeze a few times a day,  but they're like soaking through their pants once a day,  with an urge, you're probably gonna wanna tackle the urgency first. And then you can tell them you're gonna circle back on these issues at the follow-up visits  because they are gonna be coming back to you.  For nocturia, it's the need to avoid immediately preceded by sleep. So making sure that it's not that they have a partner who snores, that they have poor sleep hygiene,  or they're just, you know, don't sleep well.  You can consider a bladder diary to rule out nocturnal polyuria if the history kind of suggests, like they feel like they're having multiple large volume voids,  and I void more overnight than I do during the day. You can have them cut back fluids before bed, elevate their legs if lower extremity edema is there,  trying to time some diuretics, screening for OSA. If they use a CPAP, are they really using it? Are their settings current? Vaginal estrogen use, other things to think about,  restless legs, anxiety, pelvic floor dysfunction, and poor sleep hygiene.  Other things to think about as you're kind of counseling and evaluating patients, do they have diabetes? What was their last A1C? What meds are they on?  If they have GERD or a chronic cough, you know, can you help treat that for stress incontinence to improve their bother? If they're on anticoagulation,  can they hold it if they need a surgical procedure? That might affect what you actually counsel patients on. If they have a drug-eluting stent, last I knew it's 12 months  that they can't come off anticoagulation. So, you know, things like that might help you narrow down your discussion.  If they have a neurologic condition, how is that impacting their bladder symptoms? The easiest way, I think, to think about this is if it's brainstem or higher,  it's gonna cause overactive bladder.  If it's in the spinal cord, it can cause something called DSD, which is detrusor sphincter dyssynergia. So the detrusor muscle contracts, but the sphincter doesn't relax.  And then if they have a sacral lesion, they often have detrusor underactivity or bladder acne. And then is there some sort of functional impact if they have a neurologic condition?  Do they just not remember to void or they can't get there fast enough? And then you could counsel them on using cues like, you know, voiding on a timer and things like that.  Or if they have mobility issues, maybe they just can't get there fast enough and you would counsel them on, you know, getting a bedside commode or something along those lines.  As far as resources go,  the AugsbupQ calculator is a great one. You can download the mobile app on your phone. You could also bookmark the webpage on all the computers in your exam rooms.  Voices for PFD come in English and Spanish. iUGA, the Your Pelvic Floor, comes in lots of languages. So that can be a really great use for your non-English speaking patient.  Create dot phrases with links to patient education, handouts that patients can review via the patient portal and you can feel good about saving trees.  Posters are a pelvis model in your office to help with your discussion.  Apps for bladder diaries, Kegel trainers exist. Know your pelvic floor PTs and those in the region  and have a dot phrase to make it easier so patients don't have a barrier to getting where they need to go. And then you can also tell them about apta.org  where you can search by your zip code for a women's health physical therapist to find a place if they are coming in from a distance to see you.  And then What is Sacral Colopexy is a great video that I created when I was a fellow. It's on YouTube and it goes over kind of those perioperative expectations,  what to expect after surgery and I tell patients even if you're not having a Sacral Colopexy just fast forward through the first minute or two  and the rest is still relevant for any prolapse repair.  So that's my talk. I welcome your questions and if you have any questions or comments, feedback on the conference as we plan for next year, here's my email.  Write it down if you ever wanna discuss a patient I'm also happy to. Thanks for your attention and time.

Video Summary

Dr. Hickman delivered a lecture on patient-centered counseling for urinary incontinence and prolapse, emphasizing shared decision-making and patient understanding. She advised keeping explanations simple, using tools like analogies and visuals for clarity. Dr. Hickman reviewed conditions like prolapse, likening it to a hernia, and discussed management options from conservative treatments to surgery. For stress incontinence, she explained it as involuntary urine leakage and covered management choices like exercises, medication, and surgical options. Dr. Hickman detailed third-line treatments for overactive bladder, such as PTNS, sacral nerve stimulation, and botulinum toxin injections. She emphasized the importance of tailoring discussions to individual patient needs, recommended resources for patient education, and encouraged feedback for future lectures. Overall, her presentation aimed to enhance efficacy in patient counseling by incorporating practical strategies and educational resources.

Asset Subtitle

Digesting PFDs down to simple, patient-comprehensible content can be a challenge, especially in a busy clinical practice. This session will review strategies to streamline and simplify counseling on pelvic floor function, dysfunction and options for management, with the aim of equipping providers with the tools to counsel on prolapse and incontinence management in a manner that patients can both understand and participate in shared-decision making for their condition.

Learning Objectives:

To review strategies for explaining the diagnosis of urinary incontinence and prolapse in a way that patients can understand
To discuss approaches for patient-centered counselling on managing these conditions so that shared-decision making can be achieved
To review patient-friendly educational adjuncts that can supplement your counseling

Speakers - Lisa Hickman, MD

Keywords

patient-centered counseling

urinary incontinence

prolapse management

shared decision-making

overactive bladder treatments

patient education resources