Pelvic Organ Prolapse 101

my name is dr. Carson, I'm a board certified urologist in Washington state and now it's time for khova to dry so I have a lot of downtime and I'm really excited to be able to make this video so I've been getting a lot of requests. to talk about

prolapse

, so I'm going to answer a lot of questions that people have and that people ask me and feel free to write some questions and we can answer them too, but this will basically be like your master class. about

prolapse

, this is so hopefully we'll go over everything about prolapse, like why it happens to treatment, to the risks of surgery, this will be like a master class on prolapse 101, so when people talk about prolapse, speaks of

pelvic

organ

prolapse or a descent of basically the vaginal walls through the vagina.

I think a lot of misperceptions that people have are that your bladder is actually going to fall out, but your bladder isn't actually going to fall out, it's the vaginal walls that become weak, the muscles become weak. connective tissue weakens, low estrogen levels as people age or simply decrease muscle mass as people age, also pushing babies through the vaginal canal causes a lot of stretching and laxity that doesn't always recover , usually doesn't fully recover, so I've been doing

pelvic

s. exams for 15 years and I would say that anyone who has had a vaginal birth at least has a grade one prolapse, not always but there is always some laxity after a baby's big head has passed through the pelvis, so actually have done these studies looking at c-sections versus vaginal births for both incontinence and prolapse and vaginal births have a much higher rate of prolapse and incontinence, so there really is something about that day we spend making the baby pass through the vaginal canal, not in the nine months of pressure, but certainly just having nine months of human growth in the pelvis can also increase laxity, which is why today I am a certified urologist.

I repair prolapse all the time, except right now, because it's kovat and elective surgeries have been completely shut down, so maybe the non-operative options will be good for people right now. This is not personal medical advice. Consult your own doctor, but this is based on personal experience. The opinion of an expert. I do this for a living and then all the data and research that I know and that I can share with you, so that's your disclaimer. Think about the vagina, and so what does prolapse mean? The vagina has three sides, the front, the top, the back, the front will be where the bladder is located, the top is the cervix and uterus.

The back, behind, is the rectum, so think of the vagina, it's a hollow tube like an

organ

, but I think of it as three sides: the front, the top, and the back, as far as easy orientation, so which can have prolapse on either side, the most common statistically speaking. The most common prolapse side is the anterior wall or what is called anterior prolapse, so it is the side of the bladder where the bladder wall will come and hang down. The easiest way to rate prolapse is on a scale of 1 to 4. They have more sophisticated things. Looking at all angles is used a lot in research, but a scale of 1 to 4 is how most people talk about prolapse.

Anyone who has had a baby or lived long enough is a grade 1, which is just mild laxity of the anterior wall. and then grade 2 in grade 3 are related to where the higher mental remnant is, so the distal part of the vagina grade 2 will go down to within a centimeter of the hymen and grade 3 will come out outside the upper mental remnant and then grade 4 I'm just saying if someone has an organ or vagina between their thighs it's out most of the time so grades 3 and 4 are really surgical grade 1 and grade 2 I don't recommend people to undergo surgery.

Because I just don't think it's bad enough for you to really notice sustained improvement with surgery, certainly grade 3 on grade 4, hey Samantha, thanks for watching. So, grade 3 in grade 4, those tend to be the symptomatic ones, grade 1. and grade you're there there but only because you have prolapse or here this is what I see a lot is you'll go to your primary care doctor and they'll do a pelvic exam, they'll give you a Pap smear and whatever and I'll say "Oh my God, you have a prolapse" and then the woman gets scared and comes to see me and she doesn't mind at all, if nothing bothers you, I won't. fix it, you don't need to do anything about it, maybe talk to him. you about physical therapy and core strengthening and some things like that, but there are absolutely like I see people with grade 3 and some people with grade 4 and if they don't have dysfunction, meaning urinary dysfunction, bladder dysfunction, sexual dysfunction, if they don't have problems with that, there is no reason to have surgery as surgeons say you can't make an asymptomatic person better so if nothing bothers you I can't make you better than that so I hope that helps allay the fear just because you have Prolapse doesn't mean you have to do anything about it if nothing is bothering you and I see a lot of those people who just get scared and the doctor tells them that they have that so signs and symptoms of prolapse pelvic heaviness pelvic pressure You can feel some of that tissue when you clean yourself in the shower or when you are in the bathroom.

Severe grade 3 grade 4 prolapse can most commonly cause urinary retention. I see it as a cause of overactive bladder, so the bladder doesn't turn on. I tell people that The Bladder is not like living in the basement, it likes to live in the attic that it was born in, so when it lives in the basement or falls into that vaginal wall, it tends to become hyperactive or feel like it doesn't It's like that. emptying well or having a lot of urgency and urge incontinence, so when I advise people on how to fix their prolapse, I say that the job of surgery is to fix that pelvic organ prolapse.

I can't always guarantee that bladder symptoms will improve as with balls, so in the back, when the rectum protrudes, you will commonly be bothered by a feeling of trapped stool or even need to splint, thus putting pressure on the perineum or the vagina to strengthen that wall and make bowel movements come out. on my intake form it has, you know, splint, do you get a splint? and people will say: how did you know? because I fix prolapse for a living. I know what happens when you have a straight eel, most common with the erect eel again. back of the vagina, the most common thing with the eel rectum is a lump when you strain or feel that when you go to defecate the stool does not go down because that wall is weak and swells a lot.

It's common to have an eel rectum and it doesn't bother you at all, so don't fix anything just because someone tells you that's what your anatomy is like, but the rectum will certainly be a grade 3, grade 4 when you strengthen that wall again. bowel movements can get a lot better so that's good, other signs and symptoms, if you read about prolapse it will say pain with intercourse. Most of my women with prolapse do not have pain or discomfort from the prolapse. If you have pain during intercourse, there is probably something else going on, whether it is vaginal atrophy, low-estrogen pelvic floor dysfunction, or muscle pain, it is probably not the prolapse itself, the production is just a weekend, it's like a hernia, so it's like a weakened wall, it shouldn't "It doesn't cause pain with sex, so if someone tells me they have pain with sex, I'm very careful to say that surgically fixing your prolapse may not help with that pain with sex and, again, the upper part that is the cervix and uterus does not." There are usually a lot of symptoms when that part goes down, you may see it or feel it when you clean yourself, but what happens with sex, most people, I'm generalizing a lot, I'm sorry, but most people are mouth up or in a prone position. with intercourse and the prolapse actually goes away when you're lying down, so when I do exams I do a regular lithotomy exam or get in stirrups, but a lot of times I have women stand up and press down a little bit because I want see what gravity is doing to the pelvis, how it opens it up and lets those vaginal walls go down.

Many women with catheters will say "hey, it's great in the morning, but then I'm on my feet all day at work." or I'm gardening all day and it gets really heavy at the end of the day and that's gravity pulling those walls down so the ligaments hold up the organs, the muscles hold up the organs and various things can compromise that, so age decreases. muscle strength decreased estrogen level or postman break having multiple babies heavy lifting and straining as work standing a lot chronic constipation anything that pushes and strains chronic cough can cause prolapse certainly smoking, which weakens tissue, weakens blood flow, not good for prolapse and also the other thing you can't choose is your mom or your parents, so the pelvis that your parents gave you and the connective tissue that your parents gave you, a lot of people will say, hey, My sister had Pearls, my mother.

I had had a prolapse or my mom had something and she never talked about it now more than ever there are specialists like me who see prolapse every day, but in the older generations, the women, people didn't care about people's prolapse , number one, number two, we do. I don't have any good treatments for them that said pessaries, which are little silicone rings that you put in the vagina just to splint and hold things. Pessaries have been around forever. The pessaries are as if they were in Egyptian hieroglyphics. I don't. I didn't look it up myself, but fruit was the first, they were the first pessaries that women used, so basically you take a pomegranate and put it in your vagina to hold things up because the prolapse can get a lot worse to the point that the uterus has come out all the way and that vaginal skin and mucosa doesn't like to be exposed to air, it likes to be moist, it loves to have estrogen, so certainly a pronounced prolapse is very, very uncomfortable and can result in complete urinary retention .

I have even seen that a lot of urinary retention is causing hydronephrosis or a buildup of urine in the kidneys or severe constipation, but that is not to scare you, most people with pelvic organ prolapse, mild pelvic organ prolapse does not will progress to severe pelvic symptomatic. organ prolapse, they have done those longitudinal studies, so most people with a mild prolapse will stay mild if you have a mild prolapse, find a pelvic floor physical therapist who can work hard to lift the kegel holder and just do Pelvic floor toning exercises can relieve those symptoms. heaviness and fullness fixham, so for mild prolapse number one don't bother you, don't do anything, number two, I would say don't have surgery, get a good pelvic floor physiotherapist, ideally a woman trained in pelvic organ prolapse and stress or bladder incontinence. incontinence and if you need help finding a pelvic floor physical therapist, Herman and Wallace is a national organization that provides advanced training for physical therapists and you can always say find a pelvic floor physical therapist on the Herman and Wallace website, you can type in their code postcard I live in a city my county has about two hundred and fifty thousand people and we easily have four to six excellent pelvic floor physical therapists so they are amazing the other tool that physical therapists will use so say you have mild you have prolapse grade two you're a little bothered by the laxity you don't think it's bad enough or you don't want surgery so you can get a pessary and bother you can literally buy anything on Amazon ice pessaries help you They're like braces, they're like shoes, so you should adjust them to a certain width and depth and ideally you are the person who fits you for a pet.

Sri will also put some estrogen cream on you to really keep that skin nice and healthy so it's comfortable to put the pessary on and off, but a lot of physical therapists use a pessary as a tool, so you put this silicone ring on and it's flexible, but it It is like a nuvaring for There are hundreds of different shapes and sizes but the most common is a ring pessary or ring pessary with support, you put it on and then you go to your pelvic floor physiotherapist and you can use it as a biofeedback tool and feel your pelvis lift, which is why many physical therapists will see this. actually there is data that talks specifically about postpartum women, there is actually data that says that physical therapy with a pessary what the pessary does is simply relieve tension on the ligaments, so it supports everything and allows the body to cure around that, if you don't have a pessary, you have this great laxity all the time, so you put that pessary on andit takes the weight off the ligaments and you can heal to the point where you take off the pessary and say, oh, I'm very kind, so there's a lot of postpartum data for a lot of women, we especially don't want to hear this, the older you are to have a child. , your pelvis is more likely not to bounce as it would if you were. a 21 year old girl who has a baby, so I just always tell myself when I think I'm not calling you old.

I'm just saying that the older you are when you have a baby, the less likely it is that your pelvis will recover and I really recommend pelvic floor rehab and pessaries to postpartum moms because they are very bothered by pelvic heaviness, you have a new baby and you want to go back to be fit.that you feel like you deserve to be so I don't really ignore them, I say, let's get on with this so we can get you back to feeling as close to normal as possible, so those were the signs and symptoms that we talked about. about prolapse we talked about how prolapse occurs and then sex hurts pessaries.

I'm sorry too. Does sex hurt prolapse second question, can you have sex with a pessary so that sex doesn't hurt? I have seen many women stop having sex because they are worried that their partner or they are going to hurt their prolapse with sex. Everyone heard it. There's actually some data that says that sex and I guess orgasm is if it's a pelvic exercise, especially orgasm, which is a contraction of the pelvic floor muscles. There is some data to say that sexually active women have less pelvic organ prolapse and incontinence. The theory is that the more you exercise, the fitter you are, so there is some data that says keep having sex and it won't hurt you and your partner won't hurt you and most sexual intercourse.

Anyway, it's done in a supine position, so the prolapse comes and goes and shouldn't really cause problems again. If you have pain with sex that is never normal, come see someone who is an expert on pain with sex, so that's the second question. The question is: can you have sex with a pessary? Technically, yes, it's not contraindicated for me, there are too many cooks in the kitchen, although, oh, I say just take out your pessary, have sex, but you know, put it back the next morning, but technically yes. can I have, can I have sexual relations with a pessary in place.

I haven't seen anyone who really wants to do that, but there's my opinion on sex and pessaries, so other non-surgical options, we talked about pessaries, we talked about physical therapy to treat constipation and they'll actually give you a number 25 grams of fiber a day, which you should keep track of. I did it just because I was thinking how much is 25 grams and a piece of bread is like 2 grams and an apple is like 2 or 3 grams like they're really really hard beans they're amazing it's actually really hard to get 25 grams of fiber in your diet. every day, so most people have to supplement with a fiber product, but there are studies that say that 25 grams of fiber a day will decrease public organ prolapse, decrease bowel training, and actually , it will solve the healing of the symptomatic rectum, so if you pass hard and bulky stools from the pelvis, that symptom of pressure and weakness can go away, so for my mild rectum, ladies, I have about 25 grams of fiber and physical therapy, the most some of it is non-surgical, so increasing fiber is good for the heart anyway, really good for chronic cough, really bad for pelvic organ prolapse, weight gain and I'm not talking, I'm not talking. like 5 10 pounds overweight 20 pounds Roy I'm talking like I'm morbidly obese just putting so much weight on my pelvis the bladder hates it the bladder and the bladder is a balloon and it's also my favorite organ so I treat it like a kindergarten child.

It's like they just bully you, stop bullying the bladder, the bladder hates extra weight and the pelvis, the more you push and strain those ligaments and muscles, the more you increase the risk of pelvic organ prolapse, hence constipation. Chronic cough Weight gain All of these can increase your risk of bladder leakage and pelvic organ prolapse, so we talked about non-surgical options, it's time to talk about surgery, this is a lot, now you know that pelvic organ prolapse lasts 20 minutes. Oh my god, this is everything you ever wanted to know. I hope that if I don't answer your questions in this video, find me, ask me and I'll tell you: how did I miss that?

So let's talk about surgery so you can operate. Push it in or you can pull up so you can push it or you can pull it. It is any type of abdominal surgery. Laparoscopic surgery. The most common abdominal surgery for prolapse now is the C robotic sacral kopeck, which takes forever for people. to learn how to say that word, there are such small incisions in the abdomen that you're actually making, you're putting on a cap, so it's literally a white mesh, so the front of this is the vagina, the front of the vagina , the back of the vagina and then the Y. the mesh goes to the sacrum I personally in my practice keep the cocapec robotic vehicle seized for recurrent prolapse why number one it is more invasive it is an abdominal procedure you have to spend the night in the hospital in most cases and there is mesh involved every time you have mesh and think again of prolapse as a hernia this is a female hernia men have mesh in their inguinal hernias and it can come back just think of it as a hernia that you are trying to fix so the robotic sacral kopeck sees that they are still allowed to have mesh because it is in Toronto, there are rare and devastating complications of mesh, no matter when mesh is used for abdominal hernias, inguinal hernias, prolapse of pelvic organs, they are quite rare, but it is a long list of when mesh is placed in the body, sometimes bad things.

This happens, but it's a great repair, it's very durable, the success rates are very high because the mesh is stronger than us, so when you remove the mesh, we'll talk about how they used to put the mesh in the vagina, but now they already we do not do it. It's a mesh that actually surrounds the vagina on the inside, so the risk of erosion of the mesh into the vagina is much lower and it hasn't been pulled off the shelves like the FDA pulled vaginal mesh off the shelves, so I save the robotics, they were hoping PEC C is for prolapse recurrence, so you've already had vaginal surgery and your prolapses come back, so we'll say, "Okay, pushing failed, let's pull it unless you crush time because is stronger than you, it will give you a longer lasting hold, but as it is." your first time with a prolapse.

I don't, some surgeons will because they'll say, "Hey, in a young, sexually active woman, let's just put mesh in instead of making an incision in her vagina. The risk/benefit of her sees what you're comfortable with." surgeon". I can only talk about how I was trained and what I say about robotics, let's say your partner Peck sees four without lifting for three months for robotics, take a pair of Peck C so that you have points from the top of that mesh in Y here to his sacral ligament. the stitches have to stay and heal in place so they have a three month lifting restriction because if those stitches pop they go back down so I've had great success with the women being very happy that they recover wonderfully.

I have everyone spend one night in the hospital but then not lift more than ten pounds for three months for the robotic sacred cocapec. Let's see, let's talk about vaginal repairs, so the most common vaginal repair is the anterior repair. Remember that the most common prolapse is the front side or bladder side, so the anterior repair is more anterior. The repairs will be combined with a fixation of the sacred spinous ligament. I wish I had a pelvic model like the 3D one, it's very hard to describe, but you make an incision over the prolapse, so if your prolapse, let's say your fixtures are bulging down, then you make an incision up there and then you remove the torn fashion vaginal epithelium, you find the torn fashion pieces over here and you put them together in the middle and that flattens your prolapse again.

All absorbable sutures, most of the time we don't do them. people, it's the weird kind of academic surgeon who still puts mesh in the vagina, the FDA basically said the risks of mesh in the vagina don't outweigh the benefits of mesh in the vagina, there are no FDA approved products anymore on the shelves for vaginal repair of pelvic organ prolapse, making it a different vaginal repair than a sacral abdominal couple. Peck sees everyone pushing well. The reason is that the mesh was large, it was about the size of my hand and you placed it and then closed the vaginal epithelium. on top and I have a big piece of mesh on a very flexible organ that is sexually active and has organs that move around it and there is a decent risk of mesh contracture, pain, erosion in the vagina, painless sex and it became too much say that. the benefit was a longer lasting repair, because the mesh is stronger than its fashion, so that's the benefit and they said the risks weren't worth it, so the most common now is the old repair access, the site most common of prolapse, squeeze it to find the The torn fashion squeezes it to take a bulge and make it flat and then close the vagina over it, which is usually combined with a sake response ligament fixation or a sacral ligament fixation of the uterus, so that at the top of the vagina the upper part is taken. from the vagina and take absorbable sutures and tie them to the ligaments of the pelvis.

The most common side effect is that your buttock where it is stitched hurts a little for a couple of weeks, but it gets better. and the reason is that that is called apical support and studies show that if you do not do apical support along with your pelvic organ prolapse, that will fall again because you think that the three sides are the three right sides, anterior, superior and posterior, and if your anterior is bulging, you want to fix it, but then you want to take this and also lift it, so most of mine will be an anterior repair with fixation of the sacred spinous ligament for me in my practice, which is an outpatient surgical procedure that I send you. home with the catheter overnight because sometimes your pelvis just hurts or you're bloated or there's some anesthesia on board.

I don't want you in the ER the night of your surgery, so we'll just tell you how to get your Foley out the next night. tomorrow at home take vaginal packing at home for outpatient surgery procedure lifting restrictions six weeks do not lift more than ten pounds I put most people on vaginal estrogen I think it helps with healing blood flow keeps the university there keeps those thick, thinned and thin tissues just doesn't work as well, so I say during the lifetime cream because you had prolapse and because you had surgery, so the rectum Neil, that's the back, you can fix that if that bulges, too it bulges, so you can have an anteroposterior repair with the For the sake of responder ligament fixation, you can add a midurethral sling in there if you have stress incontinence, so you leak when coughing, sneezing, laughing.

Here's the thing if you do it if you have a severe prolapse, a severe anterior prolapse and you fix it, there is something called de novo stress. incontinence, meaning it wasn't leaking before because your bladder was a little twisted because remember living in the basement. I put it back in the attic. I changed that angle and now you're leaking. It's very annoying when that happens. I do not do it. I love it, patients don't love it, but I talked to everyone about de novo stress incontinence. It's pretty rare that you don't leak and then you fix your significant prolapse and do it.

They used to put in slings and everyone uses some kind of prophylaxis like you. You are fixing your laboratories, you probably have some deficiency in the sprinklers. We're going to put a sling on it because you're there anyway, but they found out they were putting in unnecessary slings and slings or webbing, so now we're really making you work for your webbing. you don't have stress incontinence, they don't put mesh on you, but if then you have stress incontinence and we say, hey, you're the 10% of the population that had their bladder bent when fixing your prolapse, now let's make a mesh sling to that we can talk about robots we talk about anterior pairs and posterior pairs both primary plications without mesh certainly without mesh in the posterior either sacred spinous ligament or fixation of the sacral ligament of the uterus other things to do or consider is in some women if their process was really bad so come on Look there's a vagina with your mid-high remains right with childbirth with a really bad prolapse you actually get a widening of that back part of the vagina and then you can feel a lot of laxity so two things number one: sex is not so good because a lot of laxity is what your vagina was like before the prolapse and before childbirth andnow your vagina is here because it's torn or in a PG anatomy or women with a really bad prolapse just having that uterus or that bladder has widened the introitus the vagina, so that's called paraneoplastic, basically removing that stretched tissue and then tighten the knot over the vagina.

I won't close it other than where the hymen already starts, basically where you started before babies, that's how We start with your vagina and now your vagina looks like this and women will say: I feel lax, maybe I don't feel as much sensation during intercourse sexual and then there's a type of prolapse that appears there, so you fix the pearl laughs, but Also, you do that straight eel or that paraneoplastic just to get back close to where you started without squeezing the vagina too much so it can be another little piece of prolapse surgery. More for older women, certainly, non-sexually active women, it's called an option.

Coppa lysis or closure of the vagina, basically the epithelium is removed from the top and bottom and then the vagina is sewn up, so think of a tube sock, right, the vagina is a tube sock, sorry, a vagina and that flexible tube is turned upside down. What you are going to do is put it on the back and then sew the socks so that there is no longer a hole. They are simply sewn. Success rates are very high because you can't prolapse things through a hole. no longer exists. I've seen some copal crises fail and what I think it is is chronic constipation from being overweight and then actually the whole pelvis is so weak that it's actually like there's no bone at the bottom and so just everything. and it just falls back down, so I have seen recurrence of the copal crisis, but it is quite rare that the copal crisis works as well as the robotic sacrum.cocapec look because you are literally closing a hole you can't have sex again the another thing we're going to talk about is success rate so success rate of robots high success rate of copic Isis is high interior repair the main placation is Keisha says oh no that's hectic oh my god what's medium hectic, my pace fast, my conversation fast, success rate of anterior posterior primary plication, so that's the most common surgery.

The rate of six is ​​not as high because we are using their tissues, remember the FDA recalled the mesh is removed, so the success rate is lower and many women may need repeat surgeries. How is it not necessary to repeat surgeries? Estrogen cream. Avoid lifting very heavy objects and straining yourself and that's it. Then I send everyone to physical therapy because they need to know how to lift smartly. a lot of women push through the pelvis when they lift, you have to engage the core to protect that pelvis, so I think there are studies that say it doesn't help.

I don't believe it. I send everyone to pelvic floor physical therapy afterwards. Prolapse surgery because the behaviors that caused you and it's like a male hernia correct the behaviors that led to pelvic organ prolapse in the first place, you have to correct all those structural behavioral deficiencies so that you don't restrict that pelvic floor, so I hope that Oh, Keisha clarified that she is like the closure of the vagina is agitated, yes, yes, no, that's one thing, especially back to couples classes for women who don't want their fragile right, so you can do it below of the spine, it is a shorter surgery, they do not do it.

I want to ever deal with this, so the recurrence rate, so there are many reasons for copal crisis, but it's certainly not for everyone, it's certainly not for the majority, so you can go back to anteroposterior repair with the sacred spinous ligament. the recurrence rate is higher. I had a lady and she had a big repair and she did very well because she was baling hay the next summer because she lived on a farm and she blew her old repair again, so yeah, it can, it's a whole pointing to the ground. I used to think that I actually used to think that there was a consequence of two-legged animals and that four-legged animals must not have prolapsed because you know their vagina goes this way and our vagina goes this way, but so someone showed me a video of a cow that had a uterine prolapse after giving birth and I say, oh my lord, poor cow, this can happen to our four-legged friends, so here's another question: should I ask myself a hysterectomy at the same time as my prolapse?

I'm coming in, I'm complaining mainly of anterior pelvic organ prolapse, some bladder overactivity, some pelvic heaviness when I'm white, I feel that prolapse and that's my anterior side, but I still have the cervix. I still have a uterus, should I remove it at the same time? "There have been studies that have compared this and said that you should do a preservation uterine prolapse repair, so you'll still do your sacred spinous ligament and your previous repair, but you'll keep your cervix and your uterus." I've done those studies, they think it's a wash, they think they're not doing any worse, now take it to my clinical practice, I'll fix your previous repair, but now I opened and did that tunnel again and now your uterus is going to fall on me at some point, like this I think so, it is a bigger surgery to have a hysterectomy, my ladies, I always coordinate with the guys, I do not do hysterectomies, it is a bigger surgery, it is a night in the hospital, it is certainly riskier and more invasive with hysterectomy , but It will save you from the uterus and cervix falling out again when you are older, so the pros and cons of that also increase the risk of sexual side effects or vaginal shortening when undergoing a total hysterectomy, but not all people have that, but again, there is a risk. more surgery, but your uterus and cervix will never fall out again, so I used to do in my practice.

I used to do more uterine-sparing hysterectomies than I do now because now I've seen a couple when they're coming back and you're like my prolapse is back and you're like no, the wall I fixed actually looks great, it's your uterus that's the one. which is now falling out so it's like it's the only organ you can really remove and the whole prolapse debacle so I tend to at least have a woman go talk to a gynecologist if the gynecologist says her uterus is completely well supported, let's hope at this point let's just fix what's bothering you totally fine, but that's kind of in my clinical practice, but the studies say you don't have to have a hysterectomy yes, certainly cassia, we're talking about risks of prolapse, a challenging vaginal birth, forceps, episiotomy, third fourth degree tears, all of those can lead to a pelvic floor prolapse in the future, absolutely, so the risks of surgery are risks of surgery I'm a surgeon, so I keep it simple for my patients.

I say there are five. There are always five risks of surgery. Pain. Bleeding. Infection. pills but most but they are minimal and most people don't need them plus I tell everyone there is constipation so I just say tylenol, ibuprofen and stool softeners. Long-term pain is pretty rare, especially when you're done with mesh and pain. In general, if you have pain beforehand, I'm going to think it's more musculoskeletal. Still, do you see pelvic floor physical therapists hurting from scars? It's quite rare. I put them all on vaginal estrogen which really helps with the scars by keeping the tissue soft and moist and prevents it from contracting. pain bleeding need a blood transfusion quite minimal very very rare to have severe bleeding with pelvic organ prolapse pain jump infection quite rare to have infection with pelvic organ prolapse pain bleeding infection damage to surrounding structures this is the biggest one for the pelvis out there They say God put the pelvis or God put the pipes through the playground to damage the surrounding structures, there's a lot of things down there guys, rectum, rectal injuries, ureter, ureteral injuries, bladder, bladder injuries, those are the ones. most common and all of them are very scary, we don't like them.

When they happen, it's pretty rare that someone does your surgery that does a lot of these, um, a lot of them because they're a lot more comfortable with it and they're a lot more knowledgeable about airplanes, so don't go see someone that's like, yeah. I did this in residency, how hard can it be? You don't see, you don't see that person, you see someone who makes a living making pearls and then there are still risks. Every pelvis is different, especially if you are overweight or very thin. the tissues due to low estrogen levels, the tissues are very thin or a very severe prolapse, so the planes are not at all how mother nature created them, so there is certainly a risk even in the best surgeon, so choose your surgeon wisely, a high volume surgeon who gets Back to my five pains, bleeding, infection, damage to surrounding structures, need for additional procedures, the biggest because de novo stress incontinence occurs, sometimes it occurs a recurrent prolapse and then the wound ruptures.

It's pretty rare that the need for additional procedures is really limited to those that really the most common would be changes in the bladder that we have yet to address, so if we're talking about prolapse, overactive bladder, the bladder hates living down, so we put the bladder up, your overactive bladder gets better, your urgency gets better, maybe it's not getting better. I wake up a lot at night, but remember we are not fixing prolapse for overactive bladder. A lot of people have an overactive bladder and they don't have a prolapse, so it's not one to one, so a lot of women say okay, I really hope my bladder gets better. better, it's like we expected it too, but we are fixing the prolapse to fix the prolapse, we may still have to do more work with the overactive bladder, so it's not a promise, we do pro-life surgery for the lump.

Do I need a Foley after? Yes, I do. send everyone home with a Foley, even if it's an outpatient surgery, the exception would be if it's just a disaster at sealing just the back of your bladder, it shouldn't be that complicated with me. I was having trouble urinating, but that's it. It's so funny when they say I'll have surgery but I don't want Foley, it's like Foley's are scary. People would just rather not have surgery and then wake up with a Foley catheter, and sometimes we have to talk about expectations like if we fix your broken ankle you'll wake up with a cast it's part of the healing process let's see what else that is that's 37 minutes of prolapse so we talk about what we talk about not - surgical approaches we're talking about surgery, we're talking about post-operative expectations, we're talking about you don't have to do anything just because someone says you have a prolapse, who cares, it doesn't bother you.

I can't, no one can bother a nun. happiest person, so I hope this answered all of her questions. I'm here to help you. I'm so glad I have a blessing in disguise of having some downtime during Kovan to be able to make these videos and I love talking to people about what I do. meet and empower women to seek the health care they need and deserve, so I love you. I'm going to log out. In fact, I'm here if you need me, take care.