It’s estimated that one in three women will suffer from a pelvic floor disorder – and suffer they do. Urinary and fecal incontinence and organ prolapse exact a heavy toll on a woman’s self-esteem and quality of life. Mary Fenton of Boston is a case in point.
“My mom is 80 and very independent, but as her prolapse and urinary incontinence got progressively worse – her bladder was fully prolapsed through her vagina – she wasn’t going out and doing the things she liked to do,” recalls Fenton’s daughter Eileen Fenton. “She wouldn’t go anywhere she didn’t have access to a toilet, she had to wear Depends and they were hot and uncomfortable, and she felt so self-conscious.”
Like many women of her generation, Fenton was embarrassed about her condition, but her daughter convinced her to see Tanaz Ferzandi, MD, Director of the Division of Urogynecology and Pelvic Reconstructive Surgery at Tufts Medical Center.
“Mom was hesitant to have surgery – she’d never been in a hospital before and was afraid of surgery and anesthesia – so she used a pessary for over a year,” Eileen recalls, referring to a ring inserted into the vagina to support the bladder (Ferzandi’s office offers over ten different types of pessaries for patients who choose that option). “That required going to see Dr. Ferzandi every three months to have it changed. So at my urging, Mom finally agreed to have the surgery in January 2012.”
For Fenton, pelvic reconstruction surgery entailed colpocleisis (the Le Fort procedure), placement of a tension-free vaginal tape midurethral sling using the transobturator approach (TVT-O), and a perineoplasty.
“For older women who no longer wish to have intercourse, colpocleisis is an excellent surgical option for treating prolapse,” says Ferzandi, referring to the procedure that will obliterate the vaginal opening. A colpocleisis can be performed in women who do not have a uterus; the Le Fort Colpocleisis is the procedure for women, like Fenton, who do have a uterus. After the prolapse is reduced, closing the vaginal canal can prevent pelvic organ prolapsed from recurring and can be performed at the same time as a sling procedure to address urinary incontinence.
As Fenton’s case illustrates, however, surgery is not the first – or only – treatment option available at Tufts Medical Center for pelvic floor disorders.
“We offer a truly comprehensive range of both non-surgical and surgical treatments,” Ferzandi stresses. “And we encourage each patient make her own decision about treatment depending on the severity of her symptoms and the underlying cause.”
“There are lots of treatment options that have nothing to do with surgery,” affirms Deborah Carr, RN, NP. “In cases of overactive bladder – urge incontinence – simple measures like behavior modification, paying attention to what you eat and drink, and bladder retraining exercises can be successful in reducing symptoms.
“If the patient hasn’t seen any improvement after a few months, we can move on to medications or try physical therapy,” she continues. “And there’s stimulation of the posterior tibial nerve – similar to acupuncture with electrical current, it’s done in twelve 30-minute sessions – that’s been shown to be up to 85 percent effective.”
There also are two minimally invasive options for patients with urge incontinence. One is InterStim® sacral nerve stimulation; in use for about 10years, it works like a pacemaker to control the bladder by modulating the nerves to and from the organ. Botox® injected directly into the bladder during cystoscopy is another treatment option for urge incontinence. It might require repeat injections and has excellent success rates.
Ferzandi notes that last year InterStim® sacral nerve stimulation received FDA clearance for treating fecal incontinence, and she works closely with Tufts Medical Center’s Division of Colon and Rectal Surgery to make this device available to appropriate patients.
When surgery is indicated for stress incontinence, the mid-urethral sling has become the standard of care. This is a good option for patients as it involves a vaginal approach and patients generally go home the same day, especially if not done alongside prolapse procedures. She points out that this sling is different from the vaginal mesh kits about which the FDA issued a safety warning last year – and which haven’t been used at Tufts Medical Center during her tenure.
When surgery is indicated for pelvic organ prolapse, fellowship-trained Ferzandi is skilled in minimally invasive laparoscopic and robotically assisted procedures as well as more traditional approaches for repairing cystocele, urethrocele, uterine prolapse, rectocele and vaginal vault prolapse. She also collaborates with Tufts Medical Center’s Division of Colon and Rectal Surgery on cases involving the bowel and rectum.
“We really do have comprehensive treatment options all in one place,” she says. “The key is getting women to overcome their embarrassment and talk to their PCPs or gynecologists about problems with incontinence – and getting doctors to raise the issue with their patients so they can be referred for treatment.” (See sidebar for questions to ask your patients.)
“We’re women caring for women, which can often help female patients feel more at ease,” she adds, referring to herself and nurse practitioner Carr.
“Once a woman knows you’re going to listen and take them seriously, it’s a huge first step,” Carr says.
“One of the biggest hurdles we need to overcome is the misconception that incontinence and pelvic organ prolapse are an inevitable part of aging and nothing can be done,” Carr notes. “Women are isolating themselves, they stop seeing friends, they won’t go to new places since they don’t know where the bathroom is. That’s no way to live.”
“The problems we take care of aren’t life or death,” she adds. “But they are about quality of life, and you can’t put a price on that.”
Just ask Mary Fenton’s daughter.
“We have our Mom back. It’s amazing. Her life is completely different now; she’s back to normal, doing all the things she enjoys,” Eileen relates. “She says all the time ‘why didn’t I have this surgery sooner?’ I can’t speak highly enough of Dr. Ferzandi and her team.”