Pelvic Floor Surgery: Urogynaecology (Part One) - 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. 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. Spring is finally in the air in Manchester! That's making me happy. It's taken its time. And another thing that's making me smile is that I am still receiving and very much appreciating all your lovely feedback about the podcast and, of course, about the book - available now! I can't remember if I told you this, but I found it on the shelf in Waterstones the other day, which was really quite a moment. I'd sort of forgotten that that was going to happen, but, yeah. Anyway, your messages are wonderful and reassuring, so please do keep them coming. And if you've read the book and you liked it, then please do drop a little review on Amazon because it really helps others to find it.

Today's episode is a good one. I would say that. So this is a conversation, or part of a conversation with a Urogynaecologist. And my thinking is that I want to give you a load of information about what might happen if you go to see one. So what happens in the appointment, the sorts of treatments or surgical procedures that might be available, and just some good and clear information about something I think can seem very complex, confusing and a bit scary, to be honest, maybe, sometimes. So this is Dr. Charlotte Mahoney. She's not scary. She's a consultant urogynaecologist at St Mary's Hospital in Manchester. I actually found myself in her office last year and she's lovely and I asked her to be on the podcast. This is going to be in two parts, as I say, because I want it to be useful and as comprehensive as possible, but I don't want to overwhelm. So in this half, you're going to hear us talking about a few things: you'll hear us talking about mesh, where we're at with it, about what happens during an assessment if you go to see, or get referred to a urogynaecologist, what treatments and surgeries are available for stress incontinence - which is where you leak if you cough, sneeze or laugh or jump or whatever - and the importance of physiotherapy as part of all that. And then in the other half, next week, you'll hear us talking about treatments for overactive bladder, which includes urge incontinence, which is where you just have to go right now and you can't control it. We'll look at surgeries for prolapse as well, and how to get the most out of, let's face it, your long awaited appointment. I would say listen to both of these episodes. There is some crossover. It will just make more sense that way. So, yeah, let's crack on. First question, what is a urogynaecologist?

Dr. Mahoney

So, one of my bosses makes this joke that we're a bit of urology, we're a bit of gynae, we're a bit of ology - so colorectal - and we're a bit of orgy, so we do a bit of sex as well. But we're confusing...in other countries, so in the United States and Canada, we're called pelvic medicine or female pelvic health surgeons, specifically reconstructive surgeons. So that's kind of the idea, is that we restore the female pelvic health through surgery or otherwise. We trained as gynaecologists, but then we do some urology as well. So some gynaecologists can do a bit of urogyny, so they can do the prolapse as well as the bladder stuff, but urologists will just do the bladder. They won't do, if you've got any prolapse issues or any bowel issues, at the same time, whereas we tend to try and do it all in one if we can, or we call in our phone-a-friend to come and help if it's a bit more complex.

Helen

So I guess there's not one right person that you should be seeing then? It will depend on the individual or maybe what's available in the area?

Dr. Mahoney

Yeah, very much so. It depends on you, what's wrong with you, what your symptoms are, and then what's available in your area. And that's particularly true for bladder problems at the moment in the UK, because of kind of pausing mesh, lots of urologists and gynaecologists stopped being able to do incontinence operations. So then suddenly there's only a few of us, urogynaecologists and urologists, who can. So it's very much depending on your postcode as to who's available to do what in your area.

Helen

And that's because...and maybe we'll explore this a tiny bit. But when mesh, the synthetic mesh, was being used, it was being used by lots of different um experts, different doctors in different specialisms, and now that it's not, it's really only the urogynaecologists who can do the other kinds of surgeries? Is that?

Dr. Mahoney

Yeah. So years ago, like back in the 90s, before the mesh tapes were introduced, it was the urogynaecologists, some gynaecologists and urologists, and we could do these kind of more 'old school', in inverted commas, if you like, operations. And then they invented the mesh tape. And at the time the data said that it was safer and better for women, shorter operation, worked better. And because of that it meant everybody adopted it. And so all of that surgical skill of those bigger operations was then just left to a small few for women who were quite complicated. And so the problem is now, those small few are trying to train everybody else and get through the massive backlog post pandemic, NHS and all of that, which is why there's such a kind of issue as well for women across the whole of the UK in terms of accessing stuff.

Helen

Yeah. And we'll try and get through in a minute, like some of the kinds of options, not just surgeries, but things that people might see a urogynaecologist for and what that journey might look like. But I guess while we're just talking about mesh, let's just give people a sense of what it is that we're talking about. Because I know it's one of those things I think for anyone who's got pelvic floor problems and you hear all the kind of horror stories of women who've been left with complications, it's worth just kind of outlining where we're at with it. So it's on pause at the moment and has been for several years, hasn't it?

Dr. Mahoney

Yeah. So it's been on pause for quite a long time. There's a big Baroness Cumberlege report and she's reviewed it all and said that based on her evidence, she thinks it might be acceptable to restart in a very few select cases of women and in very specific centres, probably the centres that take mesh out in the first place, like we do in Manchester, because there you have an understanding of the level of harm it can produce. So you can give women appropriate counselling about you know, what they're putting themselves at risk of. But as part of that rule, she also said we need to have a national database for these implants, and NHS England and the government are still...how do I put this? In discussions with one another about this database. So none of us are doing mesh, and that's just off the table, but equally out of the women I see in clinic, certainly I've not had anyone in a good few years be even interested and ask about mesh.

Helen

No. Well, I mean, I think it's put the fear of God into loads of people because I guess, as you say, these were operations that were done in good faith. And for some women they worked. But for many women, they have these complications where the mesh has eroded in their bodies and just life changing disabilities off the back of it.

Dr. Mahoney

That's it. And we don't know the exact number because we didn't have a register in the first place, but even if the number was one in a million, does it matter? It's a quality of life operation and the complication from that is you've ruined their quality of life, and that woman might not have had that operation as a result.

I think the worst travesty of the whole thing is that women, when they went to their health professionals, whether it's the GP, the hospital doctor, or whoever, and said, I'm having problems, they were told it was all in their head and they were kind of sent away. And I think that's part of where, understandably, the anger comes from, and rightly so. And that lack of trust, because you could probably forgive us for trying to act in their best interest. But what you can't forgive is that...same as in the 1900s when women were told they were hysterical and they were having heavy periods, it's just a repeat of that and it's just awful that we're no further on. So yeah. That's why there's still a pause on mesh and I think there probably will be for quite a while.

Helen

Yeah, so that's mesh and that's kind of where we're at, that's where it leaves us today, with some different surgical options. Let's rewind a little bit and imagine that someone's got their first appointment in your office. What is this journey going to going to look like for them?

Dr. Mahoney

So, for me, when they come, the first thing we do before I even see them is their height and weight, because that influences treatment options. We test the urine and make sure they've not got any urine infections or anything like that. And then I get them to do a questionnaire generally if they can, online, because it gives us a really good marker of their symptoms. If we do do any procedures, then we can compare how well it worked for them. Then they'll come in. I run through a few basic background questions, then I talk about the crux of the problem. So whether that's bladder symptoms, prolapse symptoms or bowel symptoms. Then I examine them. So examine their tummy, examine them in the vagina. I get them to push down as hard as they can on the couch, try and make any lump or bulge they can feel as big as they can, because it's hardly the most realistic environment. So you kind of want to give the body the chance to sort of really show you how it is for the woman when she's out in everyday life. And I always tell my ladies, don't worry if you leak on the couch. It's the one room in the whole world where we're really happy if that happens, weirdly. Because it's part of the examination. And to us that's normal. Generally speaking, if you've not got a lump or bulge or you're not leaking, you're in the wrong clinic.

For me, part of the process is always trying to normalise it a little bit, that it's okay, this is just a part of health, and there's nothing to be embarrassed about. And then once we've done that, we talk about what's going on, really. So when we think about bladder symptoms and leaking urine, for me, there are kind of two different conditions. One is leaking urine when you laugh, cough, run. My favourite question is, if I put you on a trampoline, would you leak? And most people who have that condition go, God, no, no, no. I'm not going on one of those.

Helen

Yeah.

Dr. Mahoney

You know, you get the face of horror! And that we treat because it's the muscles and kind of the connective tissue down there that's weak. So we treat that by making that area stronger. So that's with physiotherapy, the pelvic floor exercises, the way you contract and pull everything up. And that's what those electronic pants people keep buying online are for. And then if that doesn't work, there's kind of devices. So a bit like kind of like a hollow tampon that you can put in, you can get it on prescription from your GP and that kind of provides some support to your water pipe and stops you leaking.

Helen

Which is an incontinence pessary, right?

Dr. Mahoney

Yes, exactly. And they come in different shapes and sizes. I tend to find they're really good for women who maybe only leak when they go running or go to the gym and you just want to use it occasionally. And then all the way through to if that doesn't work, then we can do procedures or surgery.

So if you come to see me after physio and you don't really feel the devices are for you, and it's a personal choice, right? I'm not you, I do quality of life surgery or quality of life interventions. So it's very much...I give you the relevant options that would work in your situation and then you pick and choose what you feel would then be best for you. Because the other thing is what you might choose now might be different to what you would choose in ten years time. Because your children are older, your lifestyle is different and that's why it's so important to leave it up to you and what you want.

So once you've done the physio, the next thing we need to do is some bladder tests, usually, before we even think about an operation because I need to check you've not got another bladder condition going on, and you're emptying your bladder ok. Because if you're emptying normally, then that's great, but if you're having problems emptying, it alters our chat around the risks for any surgery you might choose. Once we've done those, you'd come back and see me and then we'd talk through the options.

So really there are three options for women with stress incontinence. So that's leaking urine with kind of the physical activity side, as in, if you put your body under physical stress, you leak. So the first one is bulking and it's where we put a kind of...it's a bit like collagen injections, you know, a bit like people have in the face?

Helen

Yeah, we've had a laugh about this before!

Dr Mahoney

It's similar-ish material, it's a hydrogel, but you put a camera in through your water pipe, your urethra, and then you do a couple of injections of this stuff into the muscle, the sphincter, that kind of sits around your water pipe and holds it all in, to bulk it out, basically. It does what it says on the tin. And then the idea is that kind of stops you from leaking. So some places do that under anaesthetic, but a lot of us have now moved to doing that under local anaesthetic and in clinic. So the nice thing about it is there's no general anaesthetic, so it's pretty safe, especially if you're not very fit and, well. It's only 30 minutes. Come to clinic, we do it, you go home again. The risk for it is really, really low. So the chances of having any problems emptying your bladder afterwards are really small. There's a small chance of a water infection afterwards or a urine infection, because we put a camera in there. That's about it, really. A little bit of discomfort.

Helen

A friend of mine had this done. It was wonderful. It changed everything for her.

Dr. Mahoney

Yeah, that's it. And in some ways, maybe it should be a first step or it's a brilliant kind of...for women who want something doing, but don't want or don't have the time in their life at that moment to have a major operation. And so it's fantastic for that. You have one and sometimes it works a bit. We'll do a top up, hopefully six weeks later, but with NHS waiting times, normally longer, and then if it fails after that, then we'll say it's a failed treatment. But, as you say, for the women it works for, it is fab, because it's really low risk. You know for ladies who might maybe be carers for their elderly husbands who've got dementia or whatever, and actually they don't want to be in hospital or have a long recovery time, it's fantastic. For women who are younger, who have younger children, again who haven't got that time to sort of recuperate from an operation, it's a great option. But what you gain in very low risk, you lose in terms of its success rate. So the success rate, based on NICE guidance is around 30% to 70%. So for every ten women I've got, between three and seven will be happy.

Helen

It's quite a range, isn't it?

Dr. Mahoney

Yeah, isn't it? Our number is probably...in my unit, it's probably around six in ten, are happy. But equally, you don't lose a lot by giving it a go. Which is what quite a few of my ladies who go for it tend to view it as. Because if it doesn't work, you can still have the operations, it doesn't mean you can't have something else. And that's the nice thing about it.

Helen

And so staying with stress incontinence, there are, I think you said, three surgeries in total? So two others?

Dr. Charlotte

Two others. So there's three kind of surgery/procedures. There's the bulking, and then the two operations now, so the first one is called a fascial sling, and it's basically when we make a cut in your tummy, similar to Caesarean section type scar, kind of around your knicker line, it's about eight centimetres long. And then we go down to your tummy wall and we take a strip of tissue from your tummy wall and then we go back underneath through the vagina and we tunnel it either side of your water pipe, or your urethra. And the idea is that it acts like a bit of a hammock. And so whenever you laugh or cough, your water pipe, or your urethra, kind of press down on the sling and it closes off, so you stay dry. Really good operation, especially since we started doing it with the tunnelling, because the risks are slightly lower.

Helen

Tunnelling?

Dr Mahoney

So we've got...it's a bit like a big needle, like a very big chunky needle that you kind of feed it behind your pelvic bone, and run it up either side of there, in an empty space.

Helen

That's starting to make me feel a bit funny...but ok

Dr. Mahoney

Yeah, sorry!

Helen

And this is using native tissue, isn't it? Nothing to do with plastic mesh?

Dr. Mahoney

Exactly. No, it's all your own tissue and it's all dissolvable stitches. So that's the really nice thing about it- it's all you. There's nothing when the operation is over, you're not going to be left with any foreign bodies inside. The success rate is around 95% or 90%, so it's really good. The NICE, again, suggests that after five years, that drops to around 75%. The big risks with it, apart from your usual surgical risks of infection, bleeding, that kind of thing, the specific ones for this are: you can get a hernia where we've taken the strip of tissue in your tummy wall, so we put extra strong stitches to close it off, but that's still a chance. And then the other risk that people will often quote to you is you're more likely to have problems emptying your bladder after that operation. But...I think that actually that information is a little bit skewed because the data it's based on is when we used to do this operation in women who'd already had failed mesh tapes and failed other things, so they were already a higher risk of having problems emptying the bladder afterwards. So it's not the same data in women where it's just your first incontinence operation. In our unit, the number of women who go home with a catheter in for about a week is probably between one in five, one in ten, just because it's swelling. And then the number of women who have to empty the bladder themselves afterwards is a lot, lot lower. One in 20 for a couple of months, and then it stops. It's very rare you'd have lifelong problems unless we identified that on your bladder test beforehand, and that would have been part of our discussion at the time as to whether or not you were happy with that or you'd rather live with the leaking.

Helen

Okay. And when you say a success, how do you judge that?

Dr Mahoney

Based on the woman's feeling of success? So her impression of improvement. So she probably felt like she was much drier or very much better.

Helen

So it's not like...obviously we're not saying we're going to put women back to how they were before they had a baby. That is not a realistic expectation when you enter into something like this?

Dr Mahoney

No sadly. Not possible, unfortunately.

Helen

Because that's what we all want, right? As soon as I have my prolapse, I'm straight on there (the internet), 'Fix it, put it back to where it was before. Thank you very much.' But obviously it's not like that.

Dr Mahoney

No. It never quite goes exactly back to how it was before. Unfortunately, no.

Helen

And then you were saying so, like, five years later, the success rate lowers again. So it's got a lifespan, that's what we're saying?

Dr Mahoney

Yes. And that's what I tell most of my ladies. Everyone laughs, but I say to them - especially for prolapse surgery, but equally, in some ways, for incontinence surgery - it's a little bit like a facelift, but for the vagina. Eventually the wrinkles come back, eventually the prolapse or the incontinence comes back. But it helps to get your head around it, to think about it in that way. We are stretchy and actually, as we get older, our skin gets more stretchy, but the rest of us does too, on the inside. And that's kind of an easier way to get your head around it, I guess. Plus lighten the mood.

Helen

Yeah. So it's a treatment or an improvement. It's not a permanent fix.

Dr. Mahoney

No, but equally you know, a good incontinence operation will last 10 or 20 years. So there's a good length of lifespan in there.

And then the other operation is a bit of a mouthful. It's called a laparoscopic colposuspension. So you can have this done, what we call open, where we make a big cut in your tummy, but most places now will offer it with keyhole surgery. That's what laparoscopic means. It just means keyhole surgery. And a colposuspension is basically where we put a camera in through your belly button, a couple of little centimetre cuts in your tummy, and then we will pull your bladder down from your kind of, your pelvic bone. And then we put permanent stitches either side of your bladder neck and lift them to a ligament inside your pelvis and hitch it up. And that kind of turns your vagina into a bit of a sling, stopping your water pipe from leaking urine when you laugh or cough. Now, the difference with this to the fascial sling is it does involve permanent stitches. Some places use dissolvable, but all the evidence is based on permanent. So, for example, in my unit, we use permanent, but we tell the women beforehand.

The other thing to say is, as a mesh removal and kind of stitch complication centre, I think I've only ever seen one of these in the entire time we've been doing this, which is quite a long time compared to all of the other mesh referrals we get. And that one stitch we think may have been put through the bladder at the time of surgery, rather than wriggled its way somewhere it shouldn't. Equally, if it does end up going in through the bladder, it's much easier to take out. You just cut it, pull, it slides out. It's not the same as trying to dig mesh out of somebody, which is a bit like getting chewing gum out of your hair in terms of how tricky it is.

Helen

And why would you have that...or the other? What's the difference? Does it just depend on the individual?

Dr. Mahoney

Personal choice. So the success rates are the same 95% and then 75%. The risks for a colposuspension are again, it might work too well, and you can't wee. And then equally, the other specific risk to that is it lifts the front wall of your vagina. So if you've got a prolapse of the front wall of the vagina, it'll treat it at the same time. So that's often why people might choose that one. But it might reveal a prolapse of the back wall of the vagina over time because it pulls the front wall up, and then in doing so, it puts the back wall under a bit of pressure. So a prolapse of the back wall of the vagina is one of the risks of that operation.

It requires a general anaesthetic, and you have to be head down for a while. So you need a reasonably good kind of lung breathing function. Your chest needs to be pretty good, otherwise you might struggle to tolerate that. But to be honest with my ladies, once we get down to those two - as long as you've not got a reason, like, you're too overweight for me to physically be able to do one operation over the other, or you've had a lot of operations in your tummy and there's a lot of scarring in there, potentially. So I wouldn't want to go in and do the keyhole surgery one because it's just asking for trouble - it usually comes down to kind of what the woman feels she likes the idea of, and I say that a lot. There's a lot of leaflets and things you can have a read of and it's whatever takes your fancy. Because once you get down to those two, in terms of surgery and outcomes, they're sort of much of a muchness, certainly in our experience, in our unit.

Helen

I'm slightly going off-piste, but I'm just trying to think...for women who have stress incontinence - and thankfully that's not something that I've experienced - but...what am I trying to say? How bad would your stress incontinence have to be, do you think, to warrant surgery? I guess again, it depends on people's lives, doesn't it?

Dr. Mahoney

Yeah, exactly. This is why that's such a good question, Helen, and you're absolutely right, because that's what a lot of women come in saying. 'Well, I put up with it for years and years because it wasn't that bad, and I thought I should just suck it up' and then suddenly it's much worse. Or they've had grandchildren and they can't run after them in the park anymore, or it's got so bad that they leak when they walk, or they bend over to do the washing and they're picking up the washing basket and they're leaking. But equally, it is about you and your life. If your big hobby is to run marathons or 10k's and that's just the thing you like doing, or triathlons or whatever, then actually, if you only leak when you're exercising, that's still a massive issue for you. Whereas if you are...I was going to say a couch potato like me, and you don't do, embarrassingly...and you don't do a lot of exercise, that's not such an issue. But running after children and picking them up on that side might be a big thing. So it is so much more these days, not about how much you leak, or my perception of how bad it is, it's your perception of how bad it is that matters, because you're the one going through it, not me. We need to do this to help you be happy and improve your life. And that's why it's a really good question.

Helen

Good. I'm all about the basic questions.

Dr. Manhoney

I love it. Cos we have to get it out there.

Helen

Actually, so we are going to get onto the other stuff as well, but just while we're on that theme as well...the other impression I had from doing all my Doctor Google stuff, which arguably I shouldn't have done, was that after you have these surgeries, you still should live a restricted life in terms of how much stress you put on your body after that, knowing that you've had a surgery and it could be undone.

Dr. Mahoney

Again, that's a really good question, and we were having this debate... see, you think that these are silly questions, but actually we debate stuff like this all the time and geek out over it. So there's a brilliant team at Manchester Metropolitan University who are doing a lot of work in terms of women and sports medicine and exercise and things. And we were talking about pelvic floor and weightlifting...and lots of professors arguing out. But our physio pointed out that actually if, for example, you are really into lifting weights but you do it properly and your personal trainer has taught you to do your pelvic floor exercise and when you're lifting your weights, actually, that's even better, because you're really strengthening your pelvic floor compared to someone who's not doing any weight lifting and not doing any pelvic floor exercises. So, again, it's so dependent on what you do, and I say that to women afterwards. For two months, you're not supposed to lift anything heavy. So nothing bigger than a bag of sugar. You feel fine after two weeks. It's not because you need to, it's because it undoes the surgery whilst it's all healing. But after that, as long as you're not lifting the sofa to hoover underneath it on a regular basis, or big bags of heavy sand around the garden. And actually, you make sure that you lift the same amount, but you do it in half sizes, so you do two trips instead of one trip with a big heavy bag. Then actually, you're going to be fine. And if you want to do exercise, that's okay too. It's just about remembering to strengthen your pelvic floor when you're doing the exercise. So probably you don't need to live as much of a restricted lifestyle as I think people think.

Helen

And when we spoke a while back you used a really good word that I hadn't heard before, and I suppose it applies at both ends, but you talked about prehabilitation. So for women who are going into surgery it's about the pelvic floor training and physio and things like that and presumably afterwards as well?

Dr. Mahoney

Yeah, absolutely. So our physios especially are really keen on prehab and I say that to my ladies. So for example, if I've got someone who comes to the clinic and she's got horrendous stress incontinence and I can see it when she's on the couch, I know in my heart of hearts that physio is probably not going to be enough. But equally, and I say this to them, it doesn't matter, because it's still really important, and it makes any surgery we do more effective because you've made all the muscles down there as strong as possible before we do the surgery. It's a bit like training really, before you do any big exercise. It's a similar kind of thing and it also then means that after the surgery you're in the perfect position to be able to, as soon as you feel able, start doing those pelvic floors again and then making everything down there as strong as possible whilst it's healing, which is even better.

Helen

Dr. Charlotte Mahoney, a consultant, urogynaecologist from St. Mary's Hospital in Manchester who, in my opinion, talks a lot of sense. And as I mentioned at the start, there'll be a part two from that same interview next week where we'll be talking about overactive bladder, surgeries for prolapse, and how to get the most out of your appointment. The other episode to flag is actually from last series which was Pelvic Floor surgery part one with the consultant colorectal surgeon Julie Cornish, which is about colorectal services where you might be referred if your symptoms affect the bowel.

Important always to say that I am not a medical expert and this is not intended as medical advice. So please seek out your own professional help.

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!