Bladder and bowel health

Expert Commentary: Peter L. Rosenblatt, MD

This week in ShareMayflowers, we are highlighting Bowel and Bladder Health. I had the opportunity to sit down with Dr. Peter Rosenblatt, Director of Urogynecology at Mount Auburn Hospital in Cambridge, MA, to discuss topics related to bowel and bladder health, and compiled the following summary:

Dr. Rosenblatt specializes in urogynecology, an area of practice dedicated to female pelvic medicine and reconstructive surgery. Patients come to see his and other urogynecology practices for issues including urinary and fecal incontinence, overactive bladder, defecatory dysfunction (difficulty with bowel movements), as well as pelvic organ prolapse. We also discussed potential interventions, both surgical and non-surgical, that he recommends to patients coming into his office with these problems.

He emphasizes that it is important to keep in mind that all patients are offered conservative management first, including physical therapy focusing on their pelvic floor. Conservative management may also include biofeedback (where patients are able to get information from a device telling them whether or not the correct muscles are being used for the activity), as well as behavioral education techniques, dietary modifications, and bladder retraining for those patients having bladder issues. Electric stimulation at the ankle has also been found to be an effective treatment for overactive bladder. Pessaries are offered as a conservative way to treat patients with pelvic floor prolapse. Pessaries are vaginal support devices made of silicone that are both safe and cost-effective. Some patients, though, choose to undergo surgery in attempts to fix their bowel or bladder problems. Most often, these patients have elected to have surgery in hopes of improving their quality of life.

Dr. Rosenblatt performs surgical interventions to treat stress urinary incontinence (SUI) where synthetic mesh materials are used to form a sling under the urethra. This surgery has a very high success rate and very few complications. Injected materials around the urethra, such as collagen, or a newer material called Coaptite, can also be used to help treat SUI.

There are many options for surgically treating pelvic organ prolapse. The majority of the surgeries he performs are reconstructive, where, as he puts it, “the goal is to restore the normal anatomy and function that has been lost with the progression of the prolapse.”

There are many less invasive procedures that may be appropriate in certain situations. For example, if a patient has been using a pessary but it keeps falling out, one option is called a perineorrhaphy, in which the surgeon makes the vaginal opening smaller. For women who have no intention of being sexually active, a surgical intervention called a colpocleisis can be performed, where the front wall of the vagina is sewn to the back wall. One of the major advantages of this procedure is that it can be quickly performed under local anesthesia. Dr. Rosenblatt carefully screens patients who may be appropriate for this procedure, and assures that there is typically very little regret in those patients who opt to have this particular surgery. As mentioned earlier, Dr. Rosenblatt stresses that as a surgeon, he needs to think about both anatomy and function. This is the main reason why he judiciously uses synthetic mesh during reconstructive surgeons. The use of mesh in reconstructive surgeries has been a topic of debate recently, but he insists that it is very helpful if used appropriately since traditional repairs using tissues from one’s own body have an extremely high failure rates. A low failure rate with mesh means that there are very few recurrences and most complications, including mesh exposure, are considered mild. If the mesh does become exposed, the patient can be given estrogen cream or can choose to do nothing if they are not sexually active and the mesh is not posing any other problems. Mesh exposures in the vagina are typically asymptomatic unless the patient is sexually active. Reconstructive surgery can be performed vaginally, abdominally, laparoscopically, and robotically. With the last two techniques (laparoscopic and robotic), long, narrow instruments are introduced through the abdomen using tiny incisions, and the pelvis is visualized using a camera mounted on a thin telescope placed into the abdomen. The video is projected on high definition monitor screens. Currently, the best success rates are experienced with the use of the laparotomy technique. The recent development of robotic surgery has led to a large increase in hysterectomies that can be done in a minimally invasive manner. Use of robotics is another popular topic of late. Use of a surgical robot allows the surgeon a great deal more flexibility of the instruments that mimic the human hand and can also compensate for any shaking of the surgeon’s hands that may develop if fatigue is encountered during the procedure. While they are costly instruments, Dr. Rosenblatt believes that the increased use of robotics appears to have led to more surgeons being able to train and offer minimally invasive gynecological surgery, something that essentially improves access to care and “anything that makes it better for women is a good thing!” /p>

We also discussed the socially uncomfortable topic of fecal incontinence Dr. Rosenblatt suggests that the current problem of fecal incontinence is similar to where urinary incontinence was nearly two decades ago—no one was talking about it, and women were embarrassed to discuss it! But once commercials advertising medications to treat overactive bladder became commonplace, women started talking more about the subject. Dr. Rosenblatt expects this will soon happen with fecal incontinence. Solid stool is the easiest to control, but a person normally should be able to control all different forms of stool, as well as gas. In his clinical experience, simply modifying the patient’s diet can make a huge difference. He recommends a high fiber diet and Imodium as needed. While a recent Cochrane review found that physical therapy to treat this problem did not improve patient outcomes, he has found that anecdotally (meaning on a case by case basis), it does. If a patient is able to do a good pelvic floor squeeze, he instructs her to perform this exercise regularly. For all others, he refers to a pelvic floor physical therapist. If conservative intervention fails, surgery is usually a viable option. Until recently, a procedure known as anal sphincteroplasty was most common, but the long term success rates of this surgery are less than optimal. During a sphincteroplasty, torn ends of the anal sphincter muscle are brought back together with stitches. Another more complicated operation is placement of an artificial anal sphincter around the anus. This is a big operation and complications such as mechanical failure of the device as well as infection are common. Sacral nerve stimulation has also recently become approved to treat fecal incontinence. A nerve stimulator is implanted under the skin to stimulate the nerves that control bladder and bowel function. Even more recently, an injectable material known by the trade name of Solesta was approved by the FDA to treat fecal incontinence. This material is injected around the anus to help close it off. Dr. Rosenblatt also developed an alternative surgical solution to fecal incontinence. He found that many women with fecal incontinence had weakness of their pelvic floor muscles. In response to this problem, he created a sling made out of synthetic mesh to re-establish the ideal pull of these muscles. This procedure is called TOPAS (trans-obturator post-anal sling) and is currently in the midst of an FDA trial.

Peter L. Rosenblatt, MD, is a fellowship-trained urogynecologist, specializing in Female Pelvic Medicine and Reconstructive Surgery, including minimally-invasive surgery for incontinence and pelvic organ prolapse. He is the Director of Urogynecology at Boston Urogynecology Associates, Mount Auburn Hospital in Cambridge, MA.