Pelvic Floor Surgery: Urogynaecology (Part Two) - Episode Transcript

Helen

Hi, I'm Helen, and this is Why Mums Don't Jump - busting taboos about leaks and lumps after childbirth. All the stuff that happens to your pelvic floor that no one ever talks about. Incontinence, prolapse, pelvic pain - problems that affect millions of women, one in three. I'm one of them. I have a prolapse. My pelvic organs fell out of place after the birth of my second child five years ago. And if you'd told me then I'd be speaking about this stuff out loud, I would have told you to give your head a wobble.

Hi, welcome back! With everything that's happened lately, I think I forgot to tell you about something amazing that's been in development over the last six months or so. It started, as it so often does, with an email from a listener who said she was a lecturer at Falmouth University in Cornwall and would I be interested in being a Practise client for her animation students? I said, yes, I very much would. And I went down to speak to them back in September about creating a short film based around the podcast. Now, quite honestly, I don't know what I was expecting, but the end result is so much more. They've used audio clips from the podcast and produced such a moving and powerful film, taking what is, as we know, a really difficult subject matter, and then creating something warm and vibrant and brilliant. It's a minute and a half long. I can't do it justice here, but please do go and find it on my website or on social media, because it's amazing. Trust me, you're going to love it. Massive thanks to Rosa Mulraney and all of the students at Falmouth. You should all be massively proud of yourselves. Thank you again.

Today's episode picks up where we left off last week, in conversation with the urogynaecologist Dr Charlotte Mahoney from St Mary's Hospital in Manchester. It's in two parts because I think it's really important, and it's accessible and that's hard to find, and I didn't want to cut it short or to overwhelm. So please do listen to the previous episode first, where we spoke about mesh, where we're at with that, about what happens during an assessment and what treatments and surgeries are available for stress incontinence, as well as success rates for that and the importance of physiotherapy. This week, we discuss treatments for overactive bladder, which includes urge incontinence. We look at surgeries for prolapse and how to get the most out of your long awaited appointment. Here we go:

Right, so we've covered three procedures for stress incontinence, and the other kind of incontinence, or the major kind, is urge incontinence or overactive bladder? Same thing, right?

Dr Mahoney

Ummm

Helen

Not quite the same thing?

Dr Mahoney

Yeah, pretty much. So basically, the other bladder condition that a lot of women have is an overactive bladder and it's where your bladder has gone rogue and it does what it wants to do. So your bladder says 'I need a wee'. And your brain says 'Okay, but we're in a supermarket right now, so don't go'. And you can almost hear your bladder going 'Haha, I'm going to do it anyway.' And then it just comes out.

And it is in some ways worse than stress incontinence because you can't control it. At least with stress incontinence, you can stop doing all the activities that start it, right? And it's awful because you have to limit your life loads, but you can at least in some way stop. Whereas with overactive bladder, you might be standing in the supermarket looking at the cereal, doing the family shop, and suddenly it just comes out and it can be big volume and you cannot stop it. And there's a puddle on the floor. And it's mortifying. So it is the needing to rush to the toilet for a wee, and then also the incontinence bit is not being able to make it in time, and it comes out before you get there. And some women get a minute's warning, some women get 2 seconds. Some women, you put your hands under hot water or you stand in the shower and you leak, or you get your key in the door and you start jiggling. You know when you've been on a long car journey, it's that feeling that every time you put the key in the door and it comes out as the keys turning in the lock.

So that is a very different cause. So that's caused by your bladder muscle being really overactive. So we don't treat that with surgery. We treat that with cutting out things that annoy your bladder. Caffeine, sadly for all the mums listening to the podcast, because that's how we survive. Fizzy pop, fizzy drinks, so even beer, unfortunately. It's the bubbles. The bladder does not like the bubbles. And then the next thing you do is you see the nurses, and they do kind of bladder training. So they train your brain to teach your bladder who's boss again, basically. And there's all different techniques that they can teach you, and they'll teach you to hold on for a second and you build up all the way up to 2 hours. And it's amazing. For the women who really engage with it, the impact that that simple thing can have is huge. It works really, really well.

Helen

That's crazy, isn't it? That's really amazing.

Dr Mahoney

It's to do with the nerve pathways. No one really understands how it works, but why question it? Because it works, right?

Then if you're still struggling after that, there's medication we can try. But one family of the medicines can give you not the nicest side effects. Dry eyes, dry mouth, you get constipated. And the problem with the medication is it doesn't cure it, right? So it's not like, you know, if you've got a chest infection and it's bacterial and it's really bad, you've got pneumonia and the GP gives you antibiotics, it goes away. That doesn't happen with an overactive bladder. We can manage the symptoms, but it's still there. So the medication is for life. And if it gives you really bad dry eyes for life, that's really annoying. Which is why we do the basics first. Again, because not only is anything I do after going to work better, if we've got the bladder training and the kind of fluid adjusting right. But also if it works with just those, amazing. Because you've avoided having to take not the nicest medication forever.

Helen

Yeah.

Dr Mahoney

And then if that doesn't work, there's another medicine. And if that one doesn't work, we do those bladder tests I talked about before, just to check there's nothing weird going on, and you can empty your bladder normally. And then after that we offer people really cool things like Botox injections, but into their bladder. So again - obviously we get all ideas from the face - but like you get Botox in the face, you can come and have it done in clinic, and our nurses do it now. So again, camera in through your water pipe with some local anaesthetic, couple of injections of Botox into your bladder muscle. You go for one wee and you go home. That's it. But that's the one where the Botox wears off, so you have to keep having it every... for some women it's every six months, for some women it's every couple of years, but it's a long recurrent treatment. But yeah, it's great. Works really, really well.

Helen

Whereas the stress incontinence Botox, that's just a one off. Is it?

Dr Mahoney

The stress incontinence bulking. So the collagen stuff?

Helen

Oh one's collagen and one's Botox?

Dr Mahoney

Yes that's how it's easy to remember the two - one's a bit like collagen and one is actual Botox. So the stress incontinence one - the bulking, the collagen type stuff - that is a one off, with maybe a top up. That's it. The Botox is indefinitely, really, but equally, you might get away with it for five years and not need one.

Helen

Okay.

Dr Mahoney

Another one is an acupuncture needle in the back of your ankle once a week for twelve weeks, for about 30 minutes...

Helen

...I know about this. A previous guest told me - it's called percutaneous tibial nerve stimulation (PTNS)?

Dr Mahoney

Amazing, Helen! Top marks.

Helen

Thank you. Thank you very much.

Dr Mahoney

Amazing. Yes, that's exactly it. Good. That means my explanation fits with what she had done. Good. Yeah. So we shorten it to PTNS because otherwise it's a massive mouthful. The great thing about that is, again, it's really low risk, but it's not as successful. For every three women, maybe one of them needs something else.

Helen

Okay.

Dr Mahoney

And then the final one is sacral neuromodulation, where you can get a little box implanted in your back, and there's an electrode - a little wire - that goes into your spine, and it runs electrical signals permanently to this nerve in your spine that basically resets your bladder and controls it. It requires a couple of operations to fit and then to kind of, as a tester to start with, and then to fit it. And the other thing is you have to have the battery changed every ten years, roughly, and it requires quite a lot of appointments because they sometimes need to rejig the settings on the box.

I don't know if it's a Manchester thing, but a lot of our women certainly tend to choose Botox over that, I think, because it seems a lot more invasive, but that's another option. Other areas, I think somewhere in Middlesborough way, they have a lot of women who go for the sacral neuromodulation instead of Botox. So I think sometimes it depends on your population and...what the vibe is.

Helen

And if you tried one and it didn't work, potentially you could have another in future?

Dr Mahoney

Oh yeah. Absolutely. It's the same with all of the things we do. You know with the stress incontinence operations as well. If you have one, it doesn't work and you come back and you want something else, we can try another one.

Helen

Yeah. Um. So prolapse then...

Dr Mahoney

Okay, go on, grill me about prolapse.

Helen

Well, I don't know really. I actually have no clue what all the different operations are, because as I say, I'm sure it depends on what's prolapsed and how bad it is, and again, what you want, right?

Dr Mahoney

Yeah, exactly. So it depends if you've got a prolapse of the front wall of the vagina, the back wall of the vagina or the top - either your womb, or the top of the vagina that's left after a hysterectomy. And depending on which bit is falling down, or which combination is falling down - because it's usually not just one, most of the time it's one and one of the others as well - it depends what combination of surgeries you get offered.

So if you've got a prolapse of the front wall of the vagina and physio has not worked - because obviously we want to do our prehab, and you want to explore non-surgery as much as possible, if you can - then we have a chat. We could try a pessary. And I know you've talked about that before, and you've had some brilliant people talk about all the really fancy different ranges and cool ones we've got. And if none of that works, then...surgery.

So the surgery for a prolapse of the front wall of the vagina is we make a cut on the front wall of the vagina. We push the bladder back up to kind of the level it should be, and then we get this connective tissue that's just underneath the bladder and stitch that together and then trim any spare skin off and then close the skin back over. It's a really...relatively simple operation, to be honest. Like I said before, the main issue is managing things before and after to make sure we've got everything addressed to reduce the chances of it coming back. And you can have it done under general anaesthetic or a spinal anaesthetic. So a bit like an epidural. You don't have to be asleep if you don't want to, or if you've got heart problems and you're older and you're worried about having that type of anaesthetic. You don't need it for this. At the moment, with us, you stay in one night. But there are places around the country that they're doing it as a daycase operation. And I'm setting that up in the northwest as soon as I can get the the overnight kind of bed stay to do that potentially as a daycase at one of our smaller hospitals as well. So that's quite exciting because, again, it just makes it more of an accessible operation for women.

If you've got a prolapse of the back wall of the vagina, we do exactly the same thing, but on the other side. So a cut on the back wall, push the bowel back down, take some strong connective tissue, tie that together, all dissolvable stitches, so it's all your own body. Trim off any spare vaginal skin and close it back over. And then, as part of that, we'll often neaten the vaginal entrance as well, what we call a perineorrhaphy. So some women, particularly after childbirth, if you've had a tear and it's healed, you can still feel like the vagina is a bit gaping, and it's basically because the muscles just at the front there haven't quite healed back together exactly in the same spot. So we'll often, as part of a posterior repair, just neaten that little entrance and tuck those together slightly. Not only because it helps with the posterior repair, but it also helps to kind of keep everything tucked inside. And it gives you that normal sensation back that some women have lost when they have sex because of the gaping entrance.

Helen

So that...I mean you've described it in quite a simple way. So those two, are the two main options when it comes to prolapse, then?

Dr Mahoney

No. So those are the two main...they are the only options for a front or a back wall prolapse. The top is different.

So if your womb is coming down, we can remove your womb through the vagina. A vaginal hysterectomy. It's not like having it taken out through your tummy -your recovery is much, much quicker. Once we've done that, if the top of the vagina that's left behind is falling down too, we'll put a stitch in that and hitch it up to the side of your tailbone to lift it all off to one side. It's called a sacrospinous fixation. Really successful, nice little operation, especially if you're somebody who's having problems with bleeding or you've got a family history of womb cancer and actually you'd just like your womb out as well to reduce that risk. Or you just like that idea of that surgery.

The next one, if your womb is coming down, is I can put a stitch in the neck of your womb, you cervix, and use that, to hitch that up to your tailbone. So it's basically a bit like the other one we do at the top of the vagina. But this time around, you keep your womb. It's really useful for women who like the idea of keeping their womb, for cultural or personal reasons. In our experience in our unit, we don't offer it anymore to women who were still having periods, because we had a lot of issues with women who were having periods. Every month, when your womb swells, when you're due on, it will pull, where the dissolvable stitch was, and the scar now is, and it will cause pain. So we don't do it because actually, there are other options. Normally we say that to women, generally. We've had to take a lot of these down, it's probably not a good idea.

And then the final one is a laparoscopic sacrohysteropexy. So we love operations that sound like a big mouthful, as you can tell.

Helen

And they all sound quite similar as well, just to be extra confusing.

Dr Mahoney

Totally, yeah. The junior doctors struggle, bless them, because it's just all a big mishmash. So for that one, it's keyhole surgery, again. A camera in through your belly button, a couple of little one centimetre cuts in your tummy. And what we do is we place mesh. Having talked about mesh earlier, we are still allowed to put it in through the tummy. So mesh that goes in through the vagina is a no-no, and that's definitely known to cause quite nasty complications for women. As far as we're aware, mesh that goes in through your tummy is a lot safer. And that's what the evidence so far has shown. There is still a risk that it can wiggle its way through into your bladder, your bowel, all right, and we have seen that. And we in my centre, certainly take those out. Although most of the time that's when they've been put in with a permanent stitch. Not a dissolvable stitch.

But equally, this operation, we go in the keyhole, we put the mesh around the womb and we use that and lift that up and basically staple it off to the side of your lower spine. Some women really like it because it means that it's stronger than their natural tissue. Some women have got very, very stretchy natural tissue and they want something stronger than themselves. And as I said before, it's all about choice. They may have read everything about mesh, and the women with mesh complications might be listening to this, going, 'Oh, my God, what are they doing? That's a crazy choice!', but it's her choice and that's what matters. So some women like the idea because of that. Other women like the idea because they really want to keep their womb for, again, cultural or personal reasons, and they're still having periods. Very occasionally, women want to do it because they want to keep their womb and their fertility. So we counsel women saying that we don't know the impact of a pregnancy on this, right? And if you give birth, you have to give birth by Caesarean, because the baby can't get past the mesh, the netting that's there. There are cases reported where women have successfully got pregnant, carried a baby and delivered a perfectly healthy baby by Caesarean. As far as we're aware, there are still no cases reported where it's caused any problems, but we don't know. So we just say we don't know. But for some women who want to maybe keep that as an option, that's there.

That being said, in the northwest, we don't do so many of them. Again, our women tend to prefer other operations, but there are areas down south, for example, Oxfordshire, women are still very keen on mesh in the Oxford region and they tend to be quite keen on that operation. So again, it's about your area, it's about what your women want, and it's about giving them that choice and that information, and they choose. Most of my ladies in clinic, I give them all three options. If they're still having periods, I tell them in the middle option, hitching the cervix is not appropriate. And then they'll normally give me quite a strong reaction to mesh. Either they love it or they hate it. It's a bit marmite, which makes it quite easy in terms of a decision. So that's kind of if your womb is coming down.

If you've already had a hysterectomy in the past and the top of your vagina is falling down, called a vaginal vault prolapse. So that's what we call the top of the vagina that's left behind. We call it the vaginal vault. If that is falling down, your surgery options are: hitching that up to your tailbone using dissolvable stitches, exactly like we'd do after the vaginal hysterectomy, but we just do that because you've already had your womb out.

Or a mesh option - so, laparoscopic sacrocolpopexy. Another wonderfully easy phrase to say. So keyhole surgery again, and this time around, we put the plastic netting over the top of the vagina that's left behind after the hysterectomy, and we lift that up and staple it to the side of the spine and cover the mesh over with your natural tissue.

Choices for that are a little bit different. So every woman gets given the options either way. Some women are not fit for the keyhole surgery operation because of their chest. Some women have already had the sacrospinous fixation before and it's failed. And that's why they're then in a position where they're considering the mesh, because they've tried everything else and nothing's working and they've tried the pessaries and they're all falling out. And now they're walking around sat on what feels like a plum, a very uncomfortable plum or an orange, and it starts rubbing on their underwear. You know, you can get ulcers in the skin. It can be really uncomfortable and unpleasant for those women. So that's why they might choose that mesh operation. And again, that's why we give them all the choice. It's up to you what you want.

Helen

And is it possible to say, with all of these again, success rates and longevity. Does it vary or...how do they do?

Dr Mahoney

It varies to some degree. If we're completely honest, we don't totally know yet. There was a big study a number of years ago comparing all of them. The data is coming out. As far as we know, to some degree, they're all pretty much of a muchness, relatively. And certainly for us in the kind of mesh complication era, as I say, for most of our women it's usually quite a strong response either way. Either they love it or they hate it. And so we're always guided by them and what they want to do and take it from there.

Helen

Yeah, but you could hope to come out of any of these surgeries...you could have a reasonable hope that you'll be in a better position than you were when you went in, and that it will last for maybe ten or more years?

Dr Mahoney

No. So prolapse surgery is different. Prolapse surgery can fail much sooner, and it can last much longer. So one in three women with prolapse who have prolapse surgery, it will come back. And one in ten women need another operation or end up having another operation. So with prolapse surgery especially, I really use the whole wrinkle scenario, because it helps you to get your head around it. Especially if you've done some physio, you don't like the idea of pessaries or you're using a pessary but you think you might want surgery because you think surgery is permanent. Actually to have that discussion with someone like me, to have all the choices and go 'But look, actually there's no guarantee surgery will last forever.'...It influences your decision making.

Helen

It's important to hear that. Definitely.

Dr Mahoney

Yeah. And I think the other thing is, certainly in my unit, every woman I see for incontinence or prolapse, one of the treatment options is do nothing. You can come and have a massive chat with me as many times as you want and then decide, 'You know what, I don't think I want to do anything' and that's okay.

You are under no pressure to choose a treatment option. Doing nothing is an acceptable treatment because it's you, it's your body. And there are women out there who have a prolapse coming down to kind of their mid thigh, and actually they don't want surgery, and they manage it with some oestrogen cream to keep the skin nice and strong and that's them, and that's just what they do, and they are quite happy and that is absolutely okay. And I think that's one of the biggest key things about urogynae, that I spent my life trying to get across is - it's you, it's your choice, it's what you want. Here's the information. I am just here kind of as your conduit, really, to give you everything that you need to know, and empower you to make the choice for yourself. Women are independent these days. We all know...we're highly educated. We know what we're doing. We can make our own choices, and we should.

Helen

It's good to hear that. And I'm sure like, well, I have actually sat in your office, so I know this to be true. But I think it's unfortunate that it takes so long for so many people to get there. And I think that's part of the thing, is when you end up that you do get your appointment and you get there, my brain is generally going, I've got to say everything in seven minutes. I want to get it all out...have you got any advice for women who've perhaps waited months and months and months to see you? How can they get the most out of that appointment?

Dr Mahoney

Yeah, it's a really good question. You're full of them, Helen, obviously you can tell you've been doing this a while!

Honestly, I would say let your doctor guide you. I guide my patients, and we do this a lot. I've done three all-day clinics in the last five days and seen 30 patients to help with the waiting list. We know. We see ladies like yourself all the time. We can tell if you're nervous. We can tell if you just need to get it all out. We'll just sit and listen and let you get it all off, and then we'll start again and ask you our questions. But equally, be happy to be guided by us in terms of your symptoms. Think of what's bothering you before you get to see us. That's always really helpful, but we're used to picking out those little phrases. And if we ask you to do the questionnaire or do a bladder diary before you come...try and do one. It speeds it up and it really makes a difference in terms of being able to jump to the next treatment step rather than having to wait for that investigation. For those listening, a bladder diary is basically where you record how much you drink and how much you we for three days. It's a faff, it's a lot of work, but it's the most helpful test we have to tell us kind of how your bladder is in everyday life. Because when you come and see us, it's 30 minutes in an office, an examination in hardly the most relaxing environment, and actually, it's probably not going to be the best representation of what you feel when you're out and about. So that diary gives us a much better picture of how your bladder is behaving. But no, just come be guided by us. And the only other thing I would say for anybody listening is if you struggle with examinations for whatever reason, just mention it. We understand. We see and examine a lot of women, and that's okay. And if you need us to take a little bit longer, just let us know. That's absolutely fine.

Helen

Yeah, I think that's really good advice and I guess just know as well that just the fact of being there doesn't mean you're on a fast track to surgery. As you've explained, you can prescribe all of the other stuff and none of the surgery, if that's the right thing for that woman.

Dr Mahoney

Exactly. Most of what I do isn't surgery. Most of what I do is all of the other stuff. That's why it's fun. It's because I get to do everything. And a lot of the other stuff works unbelievably well. The physios, especially, as you know, they're amazing. The work that they do, and they give you this personalised exercise plan, it's very different to telling yourself you've done the exercises yourself at home for however many years. It's not the same. It's just...they're amazing, so don't discount them.

Helen

Yeah. I have kept you for far too long. I think I'm going to have to split this into two episodes. Serious. Which is not a bad thing, because I think sometimes it's just good to be meticulous about these things, because where can we...this is the problem, women find themselves with these conditions they've never heard of, had no idea about, and then cannot find reliable information and sensible advice. You get lost on Doctor Google down rabbit holes and forums. I think it will be really useful. I don't know if you have any final thoughts or advice for women who find themselves in this boat, especially given that, as we've said, it could take months or even years before they would get to see someone like you.

Dr Mahoney

Yeah, so I train quite a lot of GP colleagues who are training to be GPS's, and I set up a training clinic because I realised a lot of women exactly, as you say, are waiting ages to see me. And actually, my brilliant GP colleagues, when they're not totally overrun with the catch up from COVID, can refer people on for physio locally. They can refer you on for bladder re-training with the nurse...with the local community continent service. And actually, their waiting time is much shorter than mine. And you could have done all of the basics with them before you come to me and suddenly it's so much quicker and a much smoother process for you. But final thought, I would say, is, if it bothers you, don't suffer in silence. We are here, we're busy. There's a reason we're busy. One in three women struggle with one of these things in their life. Talk to your friends, but do go see your GP, come see us. We're always happy to even just run through the options and decide to do nothing. That's okay.

Helen

That's so reassuring. Thank you very much.

Dr Mahoney

My pleasure!

Helen

I know that conversation has already been really useful because you messaged me last week about it. Thank you again to Dr Charlotte Mahoney. I'm not a medical expert. This is not intended as medical advice, so please do seek out your own professional help.

During this episode, we mentioned PTNS as a treatment. To find out more about that, you can listen back to Sara's Story from season three and the other episode to flag is pelvic floor surgery with the consultant colorectal surgeon Julie Cornish, which is about colorectal services, where you might be referred if your symptoms affect the bowel. You've been listening to Why Mums Don't Jump with me, Helen Ledwick. You can find me on socials @whymumsdontjump or online at whymumsdontjump.com The book is called Why Mums Don't Jump: Ending the Pelvic Floor Taboo and it's available to buy now. See you next week.