Chapters Transcript General Management of Pelvic Organ Prolapse Course: Improving Practice In Obstetrics & Gynecology 2024 Annual Symposium Uh, thank you so much for this in that, uh, lecture about Previa which I have not heard for the past 10 years. And I think life is so fair when we get beautiful baby like this going through the pregnancy and childbirth process. At the end of our life in women we get prolapsed, so. I would like to uh squeeze in a lot of stuff within 40 minutes so today. Um, so some of the information may be a little appeal to the superficial. Hopefully next time when I get a chance I can go into a little more in depth in one specific topics. Yeah These are my objectives trying to squeeze a lot of stuff. So basically I want to talk about what prolapse means, what causes it, how prevalent it is, and what we can do at primary setting, and when we know to refer these patients to specialty people like neurogynecologist and myself. His outlines of the talk. So before I start my talk, I will agree with Lou's general overview of what Euroa and the color means. Neurogynecology is relatively new field, uh, which HCGME started giving out accreditation from 2013. So many of students gynecologists grandfathered in about 2013, and after that, we started giving our fellowship uh A fellowship, so about 50 to 60 fellows are graduating per year. So What we do is we're basically treating pelvic law disorders that can include urinary incontinence, public organ prolapse, epic pain, as well as urinary genital related issues. So these are the conditions that I just mentioned about on top of the urinary incontinence pel prolapse, many of the patients also come to see us for overactive bladder symptoms and painful bladder syndrome. And neurogenro fistulas, which is abnormal epithelization between organs, especially in our field between vagina bladder, between vagina and rectum, and sometimes uterus to the rectum as well. These are office procedures we commonly offer as a neurogynecologists, including passo feeding, neurodynamic testing, cystoscopy with without bulking, and cystoscopy with Botox indexa in the bladder due to some muscles. And of course, nowadays, we also offer something called uh um Pay for a nerve exam in office before we take them for a second nerve maturation. Surgical procedures, the gynecologists offer are very, very. It can be done open romantically or laparoscopically or vaginally. So these are the common procedures we do offer. So let's get into actual talk in terms of pelvic organ prolapse. Pelvic organ prolapse means take a look at anything falling through the vagina. Ah, they can be uterus, cervix, vaginal walls being pushed by a bladder, or a vaginal wall being pushed by the rectum or a pair of vaginal walls coming from lateral sides of the vagina. That's why in the past we used to divide peg organ prolapse into cysto cell, rectal cell, or paravaginal or uh perineal cell. But since 1996 we started um hormonology became. Changed, so we started using pouted organ prolapse quantification which does not separate out between cystos cell rectal cell, or different subcategories anymore. There's a diagram of severity of prolapse when we're talking about um systo cell in the old thumb, uh, so this is actually the bladders rapping and oh. OK I don't have microphone, so I cannot be awake. I'm gonna just stick together like um. Stock person and then the second picture is showing vector cell and Urus holding out the one bottom on the left side and another 11 bottom on the right side is showing vaginal vault prolapse people who had his swept them in the pack. So delay. Thank you. Can you hear me? OK, so now I can move around. So John Dean is one of the guru in neurogynecology. You heard about support system 123. Residents and medical students always get graded by, OK, where is the support 1 system 2 and 3. Support 1 means that it will collapse, uh, supported by your cycle ligaments as well as caringal ligament as you see here on the cal. And then how back was supported by arcendinus uh basal pelvis, which we call it right line too. It does appeal to the right lung because it's eurosis of absental muscles. However, it is called the white line because Doctor White first discovered that is not. And then the third level is the outermost level of composed of pale bodies. Paal bodies are composed of 5 different muscles. And so next time when we have chance, we're gonna go over again, but basically it combination of both the cabois bilaterally as well as transport hang out and an external and splinter. So these are the photos. Of my acts of patience. And look what women go through and decrease their quality of life over the time. I want to tell you these are all complete for their patients. First patient, we had mainly rural stuffpe out, but you don't see a lot of bones on the carboard bottom. This is complete rural prolapse without much cysto cell and requisite. When you look at the second lay there, this laser also had complete prosthesia. However, you'll notice that this quality is very different. This means that usually the vagina is non-characterizing spread by a squamous epithelium. So over the time when pull up stays out there long, then melanopusis happens in epidelial rail and starting keratin. So the tip would come like a skin and thicker and characterize. So by simply looking at patients vagina and what's going out, you can kind of gauge how long this lady has been suffered from this condition. Ah, and the third one is also one of the main neuron prolapse along with a little bit of cystos on the top and this lady. Had liver poet from the 2 weeks coming out, neural spell out, bladder drop, and to also have para vaginal something that's likely enters still coming around the mor pulling out together. So after the re repair, regardless of any rap open vaginal laparoscopy run up, this is mainly um final outcome of most of prolapse repair. So we kind of reconstruct and look more normal uh bba and vagina anatomy. These are the examples of my exhila, some who presented with incomplete prolapse, meaning not quoting Bau but some of the organ beau, the first one here which is mainly do. And this lady mainly Europe and the latter. And the next one. Do so lure and this lady lane and this is bladder dropping down and this is the anterior portion of the prolapse again, whatever procedure they ended up giving as the repair, they ended up having normal looking boba loops up. One thing that I want to point out is that this last lay on the top. When you see erythrococcal, many of the providers somehow send the patients to rule out malignancy when we see this kind of small inversion of erythro mucosa. This happens commonly in postmenopausal women because when we don't have enough estrogen around. The uh mucosal layer of uh urethra kind of reversing out and looks like it's in the methane this area. So please provide a localized cream about twice a week around the luvira. It will rest by itself over the cut. So I'm gonna forward you with some stats, and I'm gonna move back because I realized that this incidents prevalent slides I put a lot of them and Anyhow, so long story short. If patients complain, then the prevalence rate from patients symptom report is recorded only 3 to 6%. But when we ended up doing it again, then up to 50% of women tend to have some degree of progress. So there are a lot of these comparies because of most of the reverts. First of all, patients don't complain. Think of all, some of the patients do not get to. And third of all, all the studies are done with the limited populations only. So it's very hard to gauge whatlu incidence rate or prevalence rate is. But overall, we think that the highest level of prolapse was diagnosed and been treated between the age of 60 to 69. So these are the things that I was mentioning about. Again, look at the range of prevalence. Some studies shows 2.9%, some studies grow up to 50%. But again, in real life, the rate might be a lot higher because of all these reasons. Which means when conditions like this happen, it is not definitely death or related issues, but it does impact women's quality of life. So many women nowadays, especially in developed countries, seek for management options and treatment. That means that the cost of healthcare. Increases and burden of healthcare of course increases. So this is the study done by a group of researchers looked at about 30 years of population across the country. What they found is that if socio demographic index is high, then somehow. the patients in older age group tend to have less number of prolapse, while younger patients have a stable number of prolapse, which means that the economic, economic burden of the healthcare system is kind of growing up. Who The number that I came up is that according to this, or about 10 years ago, they quoted it's about $300 million and some of the papers saying that $1.2 billion are spent. To take care of props. Same stuff and this is also same information about how much economical impact is influenced by having pelo and prolapse and it's threatened. This, I put this slide up here because it's a little more technical issues at the time of offering one of the Surgical management or addressing ethical prolapse. Well, one of the uh most commonly done and By some providers considered to be called the standard to repair apical colets is losing white mass and pull up the vaginal bolt, a whole length of the vagina and attaching two longitudinal ligaments over presecular permanly. So when we, when we are opening this procedure. Many patients who have pa organ prolapse, especially when the bladder dropping along the together, then maybe they do have underlying stress urinary incontinence as their prolapse getting worse somehow it masking threats of urinary incontinence by of urethra. So when this patients come to the office complaining of pedal and prolapse, but they say, oh, I used to nick a lot and I cough la sneeze, but after my prolapse got worse, I don't lick any more. This type of patients we do offer we operative neurodynamic testing basically that filling the bladder while supporting the bladder and Lurus back into the normal position and see whether they do have leakage that may call or lab or doing byada so that we can figure out whether this patient will leak urine after prolapse get fixed. So some group of uh researchers take this post-benefit analysis thinking that OK, if that's a known phenomena, then do we have to place the ring at the same time. Of prolapse and repair. So what we found is that the most cost effective method of managing, managing this type of patient is the brace at the time of prolapse repair, and they found that during preoperative we were dynamic testing before uh before the psychocoopex increased the healthcare costs. So, We like to look at the money, how much money is required, and from the half 7 and all this national level for many stories have been done to compare how much cost is required to do robotic scorefecture versus laparoscopic echocooppa. as you all know, robotics has been. Great benefit for the surgeons by providing a lot more dexterity and you can get to the place with the angels and more precise actions and all that. But again, it can cost a little more to the hospital, uh, especially in it so cost rates a lot higher than straight laparoscopy. Some of the studies also found that um using robot doing psychocoopraxy will increase some lower abdominal pain because we manipulate took us a little longer and But anyhow, that's one of the oldesthetic, hoping we'll be like come back and give us some more to the elegant. This is a study looking through this economic impact and burden of pivotal and prolapse. Again, it's basically saying that millions to billions of dollars required to manage this palpable and prolapse. And interestingly, Even if we all know 1st 1st conservative management option in OA O and Pao trial, but according to this study, only 11.6% being realize pass it. Let's move on to uh risk factors for haveloum program. We talked about pregnancy, talked about catsburg, and some people also will say, hey, with C-section preventing getting cat and progress. It's controversial and it's mixed data, but bottom line is no, because in order to get to C-section timing. This woman still have to carry through the baby's old 9 months of pregnancy. The pecular damage already happened during the pregnancy. Besides of that space and how many children we got, and of course genetic factors cannot be ignored and crime constipation crime cough anything increased continuous by salva accuities do increase risk of pago prolapse. So likely the answer is multibacterial. Whatever happens, whatever causes, it can impact on our core synthesis. I think I'm going back once again. So, Let's briefly talk about some molecular level of pedal and pole. It's still in and very controversial. Many, many basic positive to being looking at colors and synthesis along with a possible causes of pedicles and prolapse. So that they found. It's bad. There are about citrus that basically there's some uh economic instability that can cause it cold and synthesis, a miscommunication between paoxone andization and somehow it impact pendicular tissues including pendicular muscle and uh connective tissue and ligament, and that ended up worsening pelvic organ prolapse. This I put it in mirror to a little busy slide, but basically uh this slide is so invent. You know, we do have an amino acid. Needed to make 3 colors and halis, so. The whole process is based on all this RNA DNAation and metaroteinases as well as pigator inhibitors, and their multi factors play play a role in terms of making coin in our body. And there are some folks that estroan also have some impact in one of the signaling pathways and maybe that's why other than the age and postmenoppose women tend to have more political than progress. When we're talking about collagen, they are mainly about 4 to 5 different types in our body, and type 1 is lo found in our skin and bone, and type 3 is loosely found in collective piss. So, Usually pediclora structures have full of type 1 and type 3 collagen in our body. So some of the patients are asking me, asking, oh, so if I take a collagen documentation, will it prevent me having neutro prolapse? The answer is no, somehow at this point was because of limited data and also there is no. Actual as showing that painting color and by mouth will somehow boost up your colors and synthesis and your pet motto. OK, so again, there are multiple things can happen why we are having cavicle prolapse at this current stage, we're still looking and moving into more the letter to find the reason and cause. So hopefully maybe someday we do have some vaccine, like, you know, for the vaccine and taking it and ended up having strong kind of why not. The bottom line is whatever so happens from repetitive stress or mechanical stress, whatever happens is somehow impact harder than synthesis pathway and ended up weakening to our ligaments and connective tissue and muscle and the internal organs that are supposed to strain the pes somehow for through and through the vass. How you going for labs. It's very important whenever they show up for annual woman's health pick up. Ask the patients about symptoms and do the pelvic exam at the time of pelvic exam, please incorporate and to ask the patient doing by soda, even if you don't know how to calculate how to make the public law quantification POQ by simply asking that they are down, we can actually see how much bos uh how much things are growing up. Typically they present with oh I feel something sticking out my through my vagina at the vaginal b at this pressure. I do feel this back pain and I cannot pee and I'm having difficulty of passing my stools and I don't have same sex the dodo and I don't enjoy sex anymore. These are all category of common, commonly reported symptoms of peloin prolapse. So, it is clinical diagnosis that Uh, 1996, Richard Wa developed this quantification system. I could call PAPQ. So it's a type of research tool and it is developed because among providers we need to communicate each other when patients are moved around the clinic that we want to know what the baseline of their degree by quantify. Different comp uh compartments of the vaginal area. That's how it was developed in 1996. Up until then, we tend to use something called Bain Walker grading system. Um, which is a little simpler than topu assignment. In order to get the degree of pedagg and collapse, it's uh we're gonna do. including speculative design bilingual exam, and plus minus the vassal exam, of course neuro exam on derma palm so that you can elicinate elicit a a possible that recollect the cli verbal carbonist repla and ending relax so that we know for sure these patients still don't have any neuraly damage with the spinal cord. These are some photos from mid-century, the first one. So this man is supposed to be a doctor and this woman complained of prolap and look at this, this guy, this man doctor is not supposed to look. So faces away from the exam park and woman is standing and this guy is relying on his hand to see how much prolapse this woman has. And in the office, the first we start with both of the thiamine and this by the angle up of pelvic and leg and see how much pele and pro prolapse is present. This will not prolapse if then varies and because it's very dynamic, only in the moment when they wake up, prolapse may not be shown. And by the end of the day, after they do work and spend a long time, then the prolapse may show worse. So it's very important if you don't see prolapse and your exam, even the patients report to you, it does not mean that they don't have prolapse. It's just a matter of timing and how much it came out at the time of the exam. So it's important for you to don't say anything for patients keep saying. Something's throwing up, then you can you can invite them later away in the coming day or ask the patient to take a photo at home when things coming up so that you can see the extent of prolapse just doing. Wish are patient in France. We like to use by valve break around because it's breakable. I know now there's some companies make like break room with some uh pornal uh plastic wrap around, uh, so they can actually push away paravaginal tissue and you can see so much better, but that's more expensive and it's not useful for neuro gynecologists because we need to have some breakups. OK, let's move on to how we quantify pedagonal programs. We saw these photos multiple times and we said ko 3 by 3 tables. Um, the top portion of the numbers represent anterior vaginal wall. Bottom 3 represent posterior wall of posterior vaginal wall. And middle portion represent actual numbers of how widely general highest opens and how widely peel bodies res at the kind of pace of push and during sala and one a number in the middle rung is called proto vaginal ran. That is the only wrong number coming from when patients is relaxed. All the other 8 numbers. Other than put her back in the land are supposed to be measured when they're doing full by sidewalk. And so when you see both patients not bearing down, that does not mean anything. So these numbers have to measure, have to be measured when they are pushing during 4 by the. OK These are the stages of prolapse unlike the walker, which gives great the grazing that then 01234. Pau gives each stages 01234. So when I talk to patients, I just tell them that through the residents they have to know what the exact definition of the statements in reference to highland ring, but when you quote the patient. I'd like to talk to them this way. They do me. I feel perfect pelvis none of us who had. Pregnancy delivery going through the like as state at the very rare statero means patients have something dangling between both legs as if they have bi leg, but everything fell out through the vaina that spa would put a spade for. And when patients start seeing some boats outside of the vaginal entrance, come in and out resistible and coming out and going back that day. There are 3 minutes between stage 2 and 4. There's one man between stage 2 and 4. So then, treatment options vary depending on patients with cooling symptoms because If patient does not have any symptoms, no pressure, no valves, no problem with urination, no problem with bowel movement. Does not mean that you have to for active management at all. Observation is always a good option as long as they do not have hydronephrosis, having difficulty of empty bladder or bowel. But if they started complaining this along with some imaging back the protein, something's not right, that it's always better off to start with passway trial so that you can reduce whatever it collapsed and follow them up. After passway trial, many women don't like pass away because of multiple other reasons. I'm gonna go over the next slide. And as a last resort, the last step is discussing possible surgical options. So Doctor Bento is one of the founding members for AUDS SDS, and then I wrote some book chapters and this is a summary of how we approach patients with teloins. I think all of you will have some slight access through the app, so I'm not going to lose it, but these are the commonly available passways. There are multiple different pathways, but passways can be divided into two groups. One group is the potent pathway. Another group is which occupying customers. So as the name says, the pork will come with wing or ring with membrane or some sort of black fake uh oval or oboe with membrane, something a little more manageable lack broken. Versus space occupying pathways including doughnut, including hellhound, and including food, something more bulky and had volumes in it so that you can kind of give the bulkkiness and support at the same time. Therefore, patients who have advanced state of pedagonum prolapse between 3 and 4, it's better off to try. Fish occupy. Even if you initially start with support, pass, or so-called pastorists tend to fall out a lot quicker and easily, the patients have advanced for that. And I saw some of the patients ended up getting two different passed away, some of whose does not want to go into surgical. Management and patients are not optimized for surgery, then some of the patients get dentist had two different passies at the same time. And one thing that I also want to let you know is that there's a cube shape. Passed away here, OK. So unlike all other passways, they can stay up to 3 to 6 months before it comes out and then cleaned and uh going back in. But they through the form. That does have a little ring together so the patient can grab it easily to remove. Unlike all other pass tube has fixed opposite. That means it's kind of sucking all 360 degrees of vaginal walls and can give big time erosion. So it is actually recommended for. To pay patients have to learn how to take it out and put it back every night. Otherwise it can cause a lot of vaginal irritation. Although this picture does not show, there's also path called inflatable pathway. So it's like a balloon, and with that bulb that you can squeeze anyway, patients that really should prolap and none of the pathways work because everybody's is different and it's dynamic and changes the corridor over the time. So none of these fit perfectly. If that's the case, we can try inflatable pass away, so you put the pathway with the rubber, and then you inflate as much as you can. Paton feels comfortable, and then put the stuff in play. People were not long ago, you know, in our life, in our human history. Women always bear the babies and had pregnancy and delivery, so. Long as long as all women suffer from pedally products. Nowadays we do have all this like dances, physical made pastels, and surgical options, but in the past we did not have any of those. So according to um the hypocrite, they use the pomegranate, the, you know, the littleru dog that had little space in it, and they used it as the passage. And believe it or not, one of the treatment options for pedal and prolapse is called the subsection. So basically put the woman upside down, hanging the bit up so that as long as possible, the prolapse can be reduced back into the pelvis. So that's what they did in the past, but I'm glad now that we have some tools available. And, and before the silicon baseac came out, many of the old like egg print and nonconsentalists, they used all this old copper lads, uh, to push this back in, but again, those metals to oxide and can do some extra problem in the vagina. So enough for passways, possible complications from passways. Any patient who desire passed away, we gotta have them just spend some time to count the patient what you expected because this small population studies, what they found is that up to more than 30% of patients complaining of increased basinal discharge. No brainer because they're folding thin and the vagina, but then I want to make them more discharge to the vetate and clear out. So as long as pattern of discharge did not both smell greenness and having very uncomfortableness, it's OK to walk for the uh paternal dear, but if it is neglected. It can cause bleeding, erosion of the epithelium of the vagina. Worst case, it can put into the bladder or into the rectum, then it could become problem. So that's why he is not recommended someone who. You think, knock on the follower, someone who's to me it and does not have cared about to bring the patient back into the office. And someone who has active unknown source of bleeding, some of who has first vaginal mass placed and almost being exposed, some of who also have malignancy, some of who have radiation likely or some sort of local radiation therapy. Histories are already cut down and that. These patients, I would suggest to try passages. But again, all other populations first active management option is offering estate. Up to 50 to 70% of patients are happy at Paula's capability, but the other. 30 to 50% of patients for variety of reasons they don't like it, and many patients ended up losing pathways when they are still sitting on the toilet to have bowel movement. So let them know since it's made of yum with metal, if it both into the toilet, they have to pick it up out of it otherwise it's gonna cause the uh toilet. Oh. OK, so this is possible complications from pass away, um. The that photo, yeah. You can see it down, you see this patter with Gho, the cap and pottery, they are inside the bladder right now. And when patients have wings they passed away right as the ring, somehow his patients have hysterectomy toy and put you through the vaginal cuff, and now it is sitting inside the pelvis. So one orcadia is that nowadays, all the top north of passages, especially wing shape do do have some metal pieces. So that metal piece like one half, won't have like this. So it falls only this angle. Not this angle. That's how we maintain pass inside of the vagina, not folding out because of that, when they have to go on airplane and go through this ex-ray machine and all that, then patients have to inform them when they have that kind of passage, which it may um. It may be the Alang, but first to be aware there's some piece of metal inside the ring chain. And the little photo is kind of that you see the ring support shape of the passary which is procured into the vaginal cup. That's the same thing as the way on the right side panel, it does show there are two rings in here that actually put inside the mirror visible now. That that OK, so one real things can happen with has space inside without being tapped for a long time. So it's really important to have a tag every 3 to 6 months. Thanks to the COVID up until COVID came along, we say, oh, test will take every 3 months. But after COVID, many patients could not get out of the house and come to visit the clinic. So some new studies done, but if we weigh out more than 6 months, will, will it increase risk of complication from having passage. And the resources found that there's not much equipment. So that's why nowadays we say passive take between 3 to 6 months is fine, and some patients who know how to self clean, self-insert passways, they can go up to 9 months for regular checkup. I'm not gonna fool you with all this possible surgical management in detail, the steps of surgeries and what to do, but I'd like you to know what are general approaches when you're talking about surgery. Oh, if I forget and move on to partially, one more thing is that there are certain types of passways being used for preventing preterm radar and preterm deliberate, but some of the things will look like red and smi parts, and Like the baba. I'm gonna look up to see you. All right. So, you know, the soup looks like. This guy and this guy and something more like a hollow space in the middle and kind of the kring state. There are several types of pestoists looking like that. Many European countries being realized that kind of pestoist thinking that we may. To create tens of had in preterm labor or pre he preterm delivery. However, they is all mixed, so I'm not sure um how efficacy this thing is and comes up over there. All right, so when we're talking about a story today, I'd like to start conversation with a patient theywe. Do are they older like a 78. Are they get to the app. Are they rerote, but they're planning to have a boyfriends. So, first question. To ask someone who's older population, then they tried to pass away, failed the pastry, and they're so miserable because everything falling out and all this stuff. Then, If they are advantage, no interest in that because in the booker and not a good candidate failed to pass away, if that's the case, that first opt them to offer is something called oberative pro that means closing up the vaina by different ways. One way is if they do have 0. And never have postmen and neuron lining is normal, low chance of having neuron cancer or ovarian cancer and all that. Then we can clip the neuro and push the ur back in and make the that are cold and tight so that things stay in and they don't feel pressure anymore. The rate for this type of procedure is called it 95 to 100%. Although if this type of procedure is done. Younger population like 160. Not bad, then the rigor rate can go up to 9%. So it's very tricky because even patients at the time think that, oh, I want everything that because back then, I'm not interested in course and all that. But as younger uh when patients are younger, the vigor rate goes up. So you have to have neutral decision after all this passable. Counseling Polk with the patient, some of the patients who have a hysterectomy done by enter a cell and be a vote coming all the way out, then we do have something called either hoocopolais or part of vaginectomy. Meaning that protocopo crisis means after denuding all this basin of them and push all our internal structure back into the pelvic and make the vagina shorter and pier by placing general panulatta and pass by an act to the said take up the sina by genuine. And clipping all this and deposit actions and again closing the entrance with the per that that very visa code of little proche though works really well for selected population and patients go home and all that. The next conversation will have to happen. If patient does not want to have those want to have sexual capability in the future, then we call it reconstructive surgery. When we talk about reconstructive surgeries, it could be another hour or more because there are multiple different ways of electing work who sizzle with the board into the light. These are some of the factors when we decide what kind of procedure we can offer with the patient, that the patients ages and whether they will have more children or not, which is very important, what kind of ruin the affectatory symptoms they have, whether they want to keep the ure because some of the women bother you. A lot having uterus inside because they feel themselves without Urus they don't feel like they're women anymore even if they know. They'll link past menopause. We don't do anything, but there is some attachment by some of the votes, and of course patients come and surgeons of uh uh ability of that type of procedure and all these things come in when we decide what type of procedure we're gonna be. These are some of the problems like how we sit them vaginal car using the ligament sacrosperous ligament ileal coccyous muscles, and how do, how we do and can put the cobra, but this and saccocorpopoxy with right mesh, just a little photos of that. Of course, any surgeries can come with possible complications. These are some of the common complications for each different type of procedure. Even if I call it as common, it does not mean like 1 out of 2 people who get all these complications. Complication rates are all like below 1% and sometimes 5%, but no higher than that, other than having postoperative bruising dysfunction. Post-operated UTI because it's very common to have not to be able to urinate when then only after the collapse surgery and having nuclei up to 30% at your gynecology procedure. That's why all the lots of providers who do categorgra products in the pair, they like to do something called active building trial before we send the patient home because post-operative during a retention rate. And vary for some of the story called up to 40%. So we like to have the bladder before we send them home by battering the bladder with about 3060 and ask them to go hopefully within 200 to 30 minutes and the post voting raises room to be less than 1/3 of whatever you do. OK OK, special populations, we talk, this talk is mainly designed to talk about all this that will be special topics as well today. The pregnant lady can also have that. If some of the food is pregnant, you need a postpartum, going to have more kids than the u. to conservative melody in petitively or exercises. These are about not the populations who consider having public and prolapsoly because after they have subsequent deliveries and pregnancy, all this repair may not be that useful, and they may have been going through another process again. So it's very important to counter them a little too very loud, and hopefully we can find the best living part of it. Of elderly patients, as we know now WHO call agent at the PD. So we're gonna, we live with uh society. Most of people now live out they are 70 and 8 years old. That means we're gonna stay around more population with the political and polar. So special attention is needed, especially as the patients as well, and more than 2/3 of our population are either overweight or obese. Does that mean that we have to wait all this all patients have to lose the weight before we can over active both for management, because some of the studies shows that the recurrence rate after prola repair in ob patient versus non-obic patients are similar, not high in obe patients. We'll treat them with care and some more compassion. Can we prevent purposezo prolapse as of now? No, we cannot prevent primary reasons because we don't know what primary causes are yet. We're still working on molecular level uh pathogenesis or pele prolapse. But for second, secondary public and that we can definitely counsel the patient who not to too heavy doing public exercise and all boys ain't doing too much but so take care of the stuff or have a medical problem if you do have chronic cough, yeny, chronic constipation, and treat them so that you don't have to carry all this salva all the kinds. Pet a prognostic that pull up again it's very hard to say, but some group of researchers looked at about 250 women, and they found that 11% over the course of time got worse and 3% somehow improved. Who knows? So if dynamic, we don't know what the actual prognosis is, but one thing that I can tell you for sure is that when patients bring you. On pass away for a longer time then they pass away at theneed somehow they collapsed reversed for progress and stayed inside the bi designer, not losing out for a long time. So that's known phenomenon, but some places who really used the tele for a while and they took the oath very uncomfortable running it out and But to pass out when they come back in 5 months, they may not do in prolap. It's a fact from a long standing passive in the past. So these are the summary of what I want to go home with, basically, with two women with prolapse only when they have symptoms and when they have urinary defectatory problems. And activation is, we start with conservative management with typical exercise, pastor filling, lifestyle change, weight loss and all this stuff, and surgery is the last resort. And if surgery is only one option left, then we've got to spend a lot of time to determine what is the best option for individual patients. None of the prolapse prolapse surgery lasts forever. But that's the key. Many patients come in saying that affects me, then you have to let them know there's no break. But it does appear to be we can help you with symptom control, but it's not gonna last forever. So that's the main key. That's why I having conversation and counseling is very important. OK, these are my references and thank you so much for your time. Published November 15, 2024 Created by Related Presenters Woojin Chong, MD View full profile
CME Knowledge Hub
