Monday, December 20, 2010

Coordinated care offers freedom from pelvic floor disorders


For the first time in years, 39-year-old Nicole Ortuno can jump up and down when she's excited. She can go for a run without worrying about where to stop for a bathroom break along the way. Best of all, she can focus on spending time with her husband and four children, undistracted by discomfort or embarrassment.

Previously, Ortuno had to limit herself and her activities because of incontinence and other symptoms associated with disorders of the pelvic floor, the network of muscles, ligaments and tissues in the lower abdominal area that acts like a hammock that supports the uterus, bladder, vagina and rectum. If the muscles, ligaments or tissues in the area become weak or are injured, the uterus, bladder, vagina or rectum may drop down, or "prolapse," and cause significant discomfort and a range of symptoms for the individual affected.

The weakness or injury can result from a number of stressors, most frequently vaginal childbirth but sometimes even heavy lifting, or from pre-existing conditions such as connective tissue disorders. Factors like weight gain and age further increase risk. For Ortuno, having four children and a history of constipation meant she was very susceptible.

Underreported, underdiagnosed

It is estimated that nearly one in three women will at some point in their lives be affected by one or more pelvic floor disorders, and although the issue primarily affects women, about 20 percent of all cases occur in men. Despite this, the disorders are commonly underreported and underdiagnosed, and like many others, Ortuno suffered silently for years, uncomfortable about sharing her symptoms and unsure whether treatment was even an option.

"I didn't know what to do about it," says Ortuno. "But symptoms kept getting worse. I knew it was time to talk to someone."


Eventually, while jogging with a friend who is a nurse, Ortuno brought up her struggles and how they had been worsening. Her friend advised her to look into treatment. After speaking to another acquaintance in health care – this time, a physician at the Mass General – Ortuno decided to seek help from the Mass General Pelvic Floor Disorder Service.

"We created this service several years ago to provide coordinated care for the significant number of patients affected by pelvic floor disorders," says May Wakamatsu, MD, director of the Mass General Division of Urogynecology, who co-leads the Pelvic Floor Disorder Service with Liliana Bordeianou, MD, of the Mass General Division of General/Gastrointestinal Surgery. "The number is only increasing, as many experts estimate that by 2050, 20 percent of the U.S. population will be women over the age of 70."

Because pelvic floor disorders often affect several different organs at the same time, the Pelvic Floor Disorder Service is comprised of a team of multidisciplinary specialists, including urogynecologists, colorectal surgeons, urologists, a gastroenterologist and a physiatrist. The concept of an integrated pelvic floor disorder service at the MGH – a service that offers both surgical and nonsurgical treatment options – was pioneered by Wakamatsu and Bordeianou. Since its creation, numerous patients like Ortuno have benefited.


Help at last

In Ortuno's case, MGH physicians quickly discovered she was affected by a combination of pelvic floor-related issues: a cystocele (prolapse of the anterior vaginal wall), rectocele (prolapse of the posterior vaginal wall) and rectal prolapse. While some pelvic floor disorders can be corrected without treatment, Ortuno would need a series of procedures performed by both a urogynecologist and a colorectal surgeon – Wakamatsu and Patricia Sylla, MD, a colorectal surgeon in the Division of General and Gastrointestinal Surgery and a member of the Pelvic Floor Disorder Service. Wakamatsu and Sylla met with Ortuno and her husband to explain the corrections she needed to get back to living a normal, healthy life.

"They were both so kind and helpful. It's easy to feel embarrassed about the topic, but they put me at ease," says Ortuno. "I always felt like I was in such good hands."


Only a short time after her initial diagnosis, Ortuno came in for the operation. Performed using laparoscopy, the surgery was complex – but it was a success. Wakamatsu rebuilt the anterior vaginal wall and corrected the cystocele by repairing injured tissues surrounding the bladder as well as the posterior vaginal wall. Sylla removed the excess colon and rectum, repairing them with sutures to avoid laxity and prevent recurrence in the future.

"It's great to be able to combine surgeries as we did in Nicole's case. One surgery, rather than multiple, means only going under anesthesia once and only going through one recovery," says Wakamatsu. "It's much more convenient for the patient – and safer."

Adds Sylla, "Combining the surgeries also allowed us to be as minimally invasive as possible. Rather than make an additional abdominal incision, I was able to repair Nicole's rectal prolapse through an incision that Dr. Wakamatsu made during the gynecological repairs."

One minimally invasive laparoscopic surgery meant a quicker recovery time and less overall pain for Ortuno. Only weeks after surgery, she was feeling better than she had in years. "This surgery changed my life. I don't have to worry about the little things any more, and I feel like I'm 20 years old again," says Ortuno. "I encourage anyone experiencing symptoms to talk their doctor about treatment."

To learn more about pelvic floor disorders and available treatments, visit the Pelvic Floor Disorder Service website.

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