Symptoms of pelvic floor disorders, such as pelvic organ prolapse and urinary and fecal incontinence, can significantly hinder quality of life. Yet many women are reluctant to seek care.
“These are very treatable health issues, but a lot of women just suffer through them in silence. There’s actually kind of a sisterhood of silence around these issues,” said urogynecologist and reconstructive pelvic surgeon Olga Ramm, MD, MS, who directs the UCSF Center for Urogynecology and Women’s Pelvic Health. “We take care of women with isolated and complex pelvic floor disorders in an integrated, multidisciplinary way, and we pride ourselves on our patient-centered approach.”
Restoring quality of life
Nicole, a 52-year-old woman with a vaginal bulge, came to see Ramm at UCSF Health. “She was feeling nervous and apprehensive and just wanted to understand why she was experiencing this symptom,” Ramm said.
Nicole had given birth vaginally 30 years earlier, had a hysterectomy at age 40, and reported occasional urinary incontinence. She was diagnosed with pelvic organ prolapse involving the bladder and rectum.
“Pelvic floor disorders can happen for a variety of reasons, but the most common are the short- and long-term effects of pregnancy and childbirth,” Ramm said. “There’s a stepwise loss of neuromuscular function with each pregnancy and delivery. There are also genetic and environmental factors, and menopause can contribute to neuromuscular decline. When pelvic floor muscles cannot carry out their supportive functions, organs can start to sag through the separated muscles of the pelvic floor.”
Ramm discussed various treatment approaches with Nicole, including both surgical and nonsurgical options, such as a pessary. Because she wanted to remain physically and sexually active, Nicole opted for a durable solution with a low likelihood of prolapse symptom recurrence. She chose to undergo a sacrocolpopexy.
“In this minimally invasive approach, we use mesh to attach the vaginal apex and the anterior and posterior vaginal walls to the anterior longitudinal ligament, which is fused to the sacral bone,” Ramm said.
Nicole recovered well and did physical therapy to help strengthen her pelvic floor muscles. Within a few months, she resumed her normal activities and felt satisfied with her outcome.
“I have nothing but the utmost confidence that everything’s OK now,” she said.
“Her chances of having prolapse recurrence over the next 15 years are around 5 to 15%,” Ramm said. “She’s maintaining a strong core and a healthy weight, which will help minimize her risk of recurrence.”
Caitlyn Painter, DO, a UCSF urogynecologist and female pelvic reconstructive surgeon, brought her expertise in musculoskeletal dysfunction to Nicole’s care. “This is a quality-of-life issue,” Painter said. “What we commonly hear from patients after these surgeries is, ‘You’ve given me my confidence. You’ve given me my life back.’”
What happens to the pelvic floor during labor?
According to Ramm, in a first-time delivery, the median duration of the second stage of labor is about 100 minutes, though it often lasts hours.
“Every birth is like a mini-stroke in the pelvis,” she said. “The longer a woman spends with the fetal head occluding blood vessels and stretching the nerves and muscles, the deeper the extent of the neuromuscular injury. No one makes choices about their family based on what’s best for their pelvic floor, but everyone deserves to know the potential risks upfront, before pregnancy and delivery.”
Ramm and Painter collaborated on a clinical risk model to predict obstetric anal sphincter injuries in laboring patients. They found several factors associated with an elevated risk of anal sphincter injury: duration of the second stage of labor, forceps or vacuum delivery, prior history of anal sphincter injury, and vaginal birth after cesarean.
Efforts to prevent cesarean delivery have led to what Ramm describes as permissive pushing. “I don’t think women are getting counseled enough about the risk factors,” she said.
“One of my research interests is the impact of delivery on postpartum mood symptoms. We found that 20% of women who suffer an obstetric anal sphincter injury develop postpartum PTSD. For half of those women, PTSD persists for a year or more.”
Ramm said many patients have told her they never knew vaginal delivery could lead to pelvic organ prolapse, urinary and fecal incontinence, painful intercourse and other pelvic floor disorder symptoms.
“Part of our mission is to educate women about potential outcomes much earlier in the trajectory of care and to trust them to make informed choices for themselves around their birth practices,” she said.
High-volume center improves patient outcomes
At the UCSF Center for Urogynecology and Women’s Pelvic Health, a multidisciplinary team of gynecologists, urogynecologic and colorectal surgeons, urologists, nurse practitioners, physical therapists and nutritionists treats patients with both isolated and complex pelvic floor disorders. The team works with each patient to design a treatment plan that reflects their unique needs and goals.
“Urogynecology is at the interface of several different specialties,” Ramm said. “We bring these experts together to provide coordinated patient-centered care, offering conservative and surgical treatments for pelvic floor disorders. There are different surgical approaches that need to be individually tailored to each patient’s symptoms, goals and risk tolerance.”
The high-volume surgical team has expertise in vaginal, laparoscopic and robotic procedures as well as advanced treatments not widely available, such as non-mesh surgery for stress incontinence and uterine-sparing surgical repair for pelvic organ prolapse.
“Robot-assisted surgery allows us to do meticulous repairs with minimal tissue damage,” Ramm said. “That translates to faster and smoother recovery for patients.”
“We also offer many nonsurgical treatments, like pelvic floor physical therapy, pessary, medications and lifestyle modification,” Painter said. “Patients who come to UCSF get state-of-the-art care from specialists who are contributing to research and advancing the field.”
“Aligning patient goals with the treatments we offer is really what makes us unique,” Ramm said.
She and the team are committed to providing an environment where patients feel comfortable discussing pelvic floor disorder symptoms and learning about effective, lasting treatments.
“Often I’ll see a woman who undergoes a 20-minute procedure that completely transforms her life,” Ramm said. “Then she comes in postoperatively and says, ‘Why didn’t I do this years ago?’ We’re living longer and expect to be active and have a high quality of life. Part of my job, day to day, is enabling people to live their lives with dignity.”
To learn more
UCSF Center for Urogynecology and Women’s Pelvic Health
Phone: (415) 353-3400 | Fax: (415) 353-9550
