ON THE FLOOR

Mr Alexander Bader of the Bader Medical Institute of London on pelvic floor issues and why women shouldn’t suffer in silence

Interview: Viel Richardson

Portrait: Christopher L Proctor

What is the pelvic floor?

The pelvis is a basin-shaped structure which supports the spinal column and protects the abdominal organs. The pelvic floor is a complex series of muscles and connective tissue in the pelvic area that has two main functions. One is to provide support and protection to the organs in the area. In the case of women, it protects the uterus and ovaries, as well as the bladder, bowel and rectum. The other function is to keep the continence mechanisms working properly. Both sexes have a pelvic floor, but we deal exclusively with female pelvic floor issues at the clinic.

The pelvic floor can be too loose or too tight. What causes these situations to develop?

The more common issue is a loose pelvic floor, where the muscles have lost their condition, been damaged or become stretched. This can happen through traumatic injury or though some of the normal functions of a woman’s everyday life. It may be the result of an invasive delivery, where there has been an issue during the birth of a child, but sometimes a normal delivery can cause some damage. A patient losing a significant amount of weight quickly can cause a pelvic floor collapse. Patients suffering from a long-term chronic cough which constantly puts pressure on the lower abdominal wall can develop muscle looseness. Also, patients who drink or smoke heavily have an increased risk.

What symptoms will pelvic floor looseness cause?

The first is urine incontinence where the patient is unable to control or hold their urine. When they cough, sneeze, exercise or do other daily activities they can leak a small or significant amount of urine. The other major issue is organ prolapse, where an organ falls or is forced out of its proper position. For example, patients could suffer a rectocele prolapse which is a prolapse of the rectum, a cystocele prolapse which involves the bladder, or a uterine prolapse where the uterus slips into the vaginal canal, sometimes protruding out past the cervix. As you can imagine these can be very uncomfortable and distressing. They can also cause multiple and recurrent infections, putting the patient at risk of more serious illness.

What about pelvic floor tightness?

This is far less common and almost always a secondary symptom caused by a separate problem. Unfortunately, it is often the result of poor corrective surgery – at our clinic around 2025% of our patients are coming to correct complications caused by previous surgeries. Possibly a woman encountered difficulties during delivery, meaning that afterwards the surgeon placed some stitches in the pelvic floor or the vaginal canal, which were done incorrectly. Primary pelvic floor tightness might be caused by an anatomical deformation that someone was born with, or by physical or psychological trauma. In the last case you are looking at a very different treatment path.

What are the symptoms here?

The impact is more severe for the patient as these women are not able to have sexual intercourse. This can be catastrophic for a couple, particularly one that wants to start a family or have more children. With tightness, the severity doesn’t matter – the woman will always suffer from significant pain. The muscles and other tissue can be stretched, distorted and can develop fibrosis, which is excessive accumulation of fibrous connective tissue. The patient won’t have suffered from incontinence, but the pain can make other everyday functions difficult.

How do you characterise the seriousness of a pelvic floor issue?

We characterise the situation in three stages: mild, moderate or severe. The determining factor is the seriousness of the impact on the woman’s life. Pelvic floor issues are not fatal, but left untreated they can have a disastrous impact on the patient’s quality of life and mental health. When it’s mild, we can treat the situation in minimally invasive ways, but with a moderate or severe diagnosis you are looking at a surgical intervention.

What are the different treatments available to you?

It is key not just to classify the severity but also to understand where the patient is in her life’s journey. For example, if she is looking to have more children, we rule out surgical treatments. With mild cases we start with Kegel exercises, which target and strengthen the pelvic floor muscles. The problem is that these can be tricky to do correctly at home. At the clinic, we have a specially designed chair, the EMSELLA chair, which can produce 11,000 contractions of the pelvic floor muscle within half an hour. It requires very little effort from the patient, is pain free and targets the muscles correctly, so is very effective. After this we might move on to laser treatment or radiofrequency. Other treatments available are biological treatments such as using the body’s own stem cells, growth factors and exosomes – which are central to communication between the cells. The aim is to improve the quality of the tissue and strengthen the muscles.

What about when symptoms are more severe?

We may have no solution other than surgery. This might involve correcting the anatomy if organs are in the wrong position, repairing things that have been damaged, or working to improve the quality of the tissue in the area. As a surgeon, your primary aim is to restore the best possible function. There are occasions where the patient says that everything is now working, but aesthetically she’s not happy. Improving the appearance is possible once the body has completely healed from the initial surgery, but our primary goal is always to correct the function, to make sure that everything is working well and positioned as close as possible to where it should be.

Are pelvic floor procedures difficult?

All surgery is difficult because you’re dealing with a living human body. But yes, pelvic floor procedures can be complex and difficult. The area contains several sensitive organs, muscles and connective tissues, all in very close proximity. There is a risk you might correct one organ but damage another. However, in the hands of a skilled surgeon who is experienced in such work, it should be fine.

Are there patients who are not suitable for pelvic floor surgery? I would advise strongly against any kind of surgical intervention for a woman planning to have children, because giving birth would destroy whatever correction the surgeon has done. Not only that, the damage would be more severe because of the previous surgery. If a patient is suffering from vaginal dryness, we need to correct that in parallel to or even before any surgical intervention. Also, very obese patients are not really suitable and if a patient has a chronic long-term cough you need to address that before moving forward.

Aside from traumatic causes, is a particular demographic more likely to have pelvic floor issues? Statistics shows that the number of people suffering from prolapse, incontinence and pelvic floor looseness increases with age and is much higher in women over the age of 80. However, that number is moving in the wrong direction. In our clinic we are treating an increasing number of people in their fifties and even forties. I believe this trend is related to lifestyle. Many patients are not well exercised, are overweight and are heavy smokers or drinkers, all of which increase your risk of developing pelvic floor issues.

What usually brings patients to the clinic?

Often, it is some level of organ prolapse, ranging from mild where things just don’t feel right to severe where an organ is protruding. After that, it’s incontinence. Unfortunately, incontinence can be a taboo subject. There is this idea that it comes naturally with age and that women just have to live with it. We are doing our best to inform them that they do not have to keep suffering, as there are ways we can help. We also get patients who come seeking aesthetic improvements.

Are there some issues that should be dealt with quickly?

In cases of severe prolapse where the organs are protruding, or severe incontinence where the patient has little or no control over urination, I need to deal with this very fast. If a patient arrives with an over-tightened pelvic floor or vaginal canal and is not able to have any kind of normal sexual intercourse, it needs to be dealt with immediately because this is a lifechanging condition. None of these will kill the patients if left untreated, but they bring an increased risk of other infections and the impacts on their life and mental health can be very serious.

Is addressing the mental health side something you do?

We think it is very important to do so. Alongside the clinical psychology department at Oxford University, we are developing questionnaires that help to detect patients who may be struggling as a result of pelvic floor issues. There will be questionnaires for both the clinicians and patients. The idea is to detect at-risk patients early so we can intervene in the appropriate way. Also, we want to follow people after a surgical correction to see how they are doing. At the moment, we are running a clinical study which will be published next year. Questionnaires will then be available to all professionals involved in this field.

What do you like most about your job?

I love my job. In training I saw many issues where the response from older surgeons was that this was entirely natural and there was nothing to be done. I thought, no. I know the anatomy and have the surgical skills, I want to see what I can do to to help. When I see patients who arrive in pain and distress coming back to my clinic, smiling, laughing, living a full life, it brings me great satisfaction.

BADER MEDICAL INSTITUTE OF LONDON

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