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We welcome Carmen Fong, a colorectal surgeon, to discuss the often overlooked yet critical topic of pelvic floor dysfunction. Drawing from her extensive experience, Carmen shares insights from the Pelvic Floor Symposiums, the challenges of treating pelvic floor patients, and the misconceptions surrounding these disorders. We’ll explore the stigma attached to pelvic floor issues, the importance of interdisciplinary collaboration, and strategies for improving diagnosis and treatment. Join us for an enlightening conversation on why addressing pelvic floor dysfunction is vital for overall health and quality of life.

Carmen Fong is a colorectal surgeon.

She discusses the KevinMD article, “Why pelvic floor disorders deserve more attention.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Carmen Fong. She’s a colorectal surgeon. Today’s KevinMD article is “Why pelvic floor disorders deserve more attention.” Carmen, welcome back to the show.

Carmen Fong: Hi Kevin, how are you? Thanks for having me back.

Kevin Pho: So Carmen’s been on before. Go to KevinMD.com/podcast to search for her name and her prior episodes. Today let’s jump into your most recent article, “Why pelvic floor disorders deserve more attention.” What’s this one about?

Carmen Fong: Sure. So I am a colorectal surgeon, and honestly I spend a lot of time doing colon and rectal surgeries, but more recently I’ve actually been doing a lot more pelvic floor.

And when I was early on in my career I was actually afraid to be pigeonholed into this niche of being the pelvic floor lady, which commonly happens with female colorectal surgeons. But after I had my first child I was like, wow, I can’t believe nobody actually ever talked about this stuff. From colorectal surgery to OB/GYN to urogynecologists, nobody actually warns you that after giving birth you might have pelvic floor dysfunction.

So I’m paying more attention to it now, especially in my patients. And we are doing a lot more in terms of anal manometry and pelvic floor physical therapy, and even Botox injections for anal spasm and anal fissures. And this is one area where I think that we need to pay more attention, not even just in some specialties but in primary care as well. So when you’re addressing disorders of like constipation, pelvic pain, it might require looking into just a little bit more, rather than just the basic, ah, I’m sure that’ll go away.

Kevin Pho: So for those who aren’t familiar with the pelvic floor, talk about what that is and how dysfunction of the pelvic floor can lead to symptoms.

Carmen Fong: Yes. So the pelvic floor essentially is several muscles that, I tell people, kind of incorporates, if you’re a female, the bladder in the front, the vagina in the middle, and the rectum in the back. And then obviously without the vagina in men. But they’re all interconnected muscles, that if they’re too tight can cause a problem, if they’re too loose can cause a problem.

I actually had one lady who was in the Association of Pelvic Organ Prolapse Survivors reach out to me after reading this article, who wanted me to come talk about constipation in pelvic organ prolapse. So when you have the pelvic floor too loose, for example, everything can kind of drop down lower, so you can have bladder prolapse which may require surgical correction, you can have rectal prolapse or vaginal prolapse which may require surgical correction.

But the more common thing though, aside from having congenital pelvic floor problems or trauma related pelvic floor problems, which could be childbirth or spinal cord injury, are these disorders of defecation that we’re finding are more and more common. So you can have obstructive defecation, which is really a very acquired way of people not going to the bathroom properly, either holding it too much and then you get pelvic floor spasm, or pushing too hard and you get pelvic floor spasm.

And in these cases, again, doing manometry, which is testing for sphincter tone and muscle and nerve control, is really helpful in defining what exactly the problem is. And then pelvic floor physical therapy or biofeedback is the first step to correcting those things.

Kevin Pho: So in the primary care office, what are some tip offs, some stories that I may hear that ring the bell of pelvic floor dysfunction and make me lead to a referral to you, or to some pelvic floor physical therapy? What would be some common stories of patients walking into a primary care office?

Carmen Fong: Yeah, that’s actually an excellent question. So the number one thing is people will say they have urinary incontinence, so you know, can’t hold in their urine, when they sneeze they pee themselves a little bit. And then we found that about 30 to 50 percent of people with urinary incontinence may also have fecal incontinence or some fecal smearing. So you know, dribbling, can’t make it to the bathroom on time, so that would be one sign. And then on the bowel side, smearing or leakage would be key words that I would look for.

And then the other main one is the feelings of incomplete evacuation. So feeling like you have something stuck. I’m like, oh doc, you know, I just keep going and going, I go sit in the bathroom three or four times a day and I still feel like something is stuck and can’t come out. So that one is a very, very good tip off to me that there might be some pelvic floor dysfunction there, that requires an exam, usually a digital rectal exam, and then some further history taking.

Kevin Pho: And then you do the conservative therapy, like pelvic floor physical therapy. What does that exactly entail?

Carmen Fong: Yeah, so pelvic floor physical therapy, I send them to a physical therapist usually once a week for about six to eight weeks, and they do several exercises. So it’s kind of like leg strengthening, like stretching exercises, but then also sometimes internal and external massage.

And then the last part of it, the biofeedback, is actually the most important part, which is a rectal balloon catheter that’s inserted into the anus and rectum, and then the patient is retrained to say, hey, when I squeeze, it holds things in, or when I push it should push out. Some people have paradoxical contraction, which is that when they push, their sphincter actually closes. And so that is a type of dysfunction where you may have encountered some constipation as well.

Kevin Pho: So you mentioned childbirth being a risk factor for pelvic floor dysfunction. Is there anything patients can do to prevent these things from happening later on?

Carmen Fong: Yeah, so it’s actually a very interesting area, because when I talk to my OB/GYN friends they will often tell you that doing pelvic floor strengthening before giving birth vaginally will actually make childbirth harder. But we’ve actually found that for most people that’s not true. You actually maybe just have increased pelvic floor strength going into it, and so that afterwards you have fewer problems. The concern is that if you have too tight of a pelvic floor, the baby’s head won’t fit through the birth canal and stuff like that. But in most cases we found that that’s not true.

The other thing though is that the risk is actually that if you push for more than two hours, there’s more than 60 percent chance that you’ll have some kind of pelvic floor dysfunction. And I just think that that should be something that OBs kind of counsel the patients on, even in their first few prenatal meetings. It might not change anything, so you probably wouldn’t be like, well, I’m jumping straight to a C-section because of the risk of pelvic floor dysfunction, but it’s something to think about.

I have friends who have reached out to me after reading this and said, oh yeah, I pushed for like six hours, I pushed for eight hours, I had no idea you could have tears and stuff and all these things going down the line.

Kevin Pho: So when patients with pelvic floor dysfunction come see you as a colorectal surgeon, what are the most common stories that you see when they eventually make it to a surgeon like yourself?

Carmen Fong: Yeah, so the two things are, it actually used to be more common that I saw fecal incontinence, and so fecal smearing of some type. So just basically laxity of the muscles after time and age, and again childbirth, or actually spinal cord injury or spinal or back surgery is a very common one.

But more recently I think, because of the proctology work that I do, I’ve actually been seeing a lot more constipation. So again, feelings of incomplete evacuation, anal spasm because of difficulty with evacuation. I’ve been treating that a lot too.

Kevin Pho: So as a primary care physician, for pelvic floor disorders, is this more a colorectal problem, a gynecological problem, or a urological problem? Like, who normally would take care of it?

Carmen Fong: You know what’s funny is that I actually think most of the time they get sent to GI, and GI does not do as much with it. Some people do, there are some very, very subspecialized gastroenterologists out there. But most of the time it’s like, well, we did a colonoscopy, there’s no obstructing tumor, therefore you’re fine. Or, oh, we put you on lifelong MiraLAX. Like, those tend to be, it is standard of care, I think those are totally correct things to do.

If it is a vaginal or urinary prolapse, I do think it should go to a urogynecologist. I think if it’s anything on the back end, a colorectal surgeon should know what to do.

Kevin Pho: So if a patient requires surgery from a colorectal perspective, tell us what you would do to fix this.

Carmen Fong: Yeah, so here’s the thing. So again, because of that 30 percent chance of overlap, the number one thing you do is actually start with a couple of imaging evaluations. So MRI defecography, doing a sitz marker study. Because if there is any kind of bladder prolapse, cystocele, uterine prolapse, you actually want to repair them all at once. And then you do need a team of multispecialty group that can actually address all of those things in one visit, because I’ve actually seen some patients who will be like, oh, I got a bladder sling three years ago but I’m still having this problem.

And the most common thing I do is a rectopexy. So a laparoscopic or robotic rectopexy, where you’re actually just putting a stitch in through the back of the rectum and stitching it to the sacrum so that it doesn’t fall out anymore.

A very, very common thing that some of my colleagues have been doing for years, that I also recently started doing, is a mesh. So a ventral mesh rectopexy, where you’re actually also attaching a mesh to it. Some patients will have a lot of concerns about the mesh. I’ve honestly never had problems, but because of the whole commercials or the lawsuits and stuff, people will always need a little bit of convincing that the mesh is safe. And I found the mesh to be absolutely safe, and it does provide a longer lasting repair as well.

Kevin Pho: So in terms of conservative therapy like physical therapy, what percentage of patients’ problems are solved by that conservative therapy, and what are the outcomes for patients who eventually undergo surgery?

Carmen Fong: Yeah, so the outcomes are actually very good. So generally in ventral mesh rectopexy, or in rectal prolapse repair with just straight rectopexy, sometimes with a sigmoid resection, it tends to be about 80, 85 percent, so which is fairly good. It does get to be a little bit lower when you’re adding things like a colpopexy or a bladder sling to it.

Pelvic floor physical therapy though has also been shown to have about 80 to 85 percent of success with just that alone. And I think it’s actually because you are strengthening muscles, you are retraining the brain. And so people who have minor symptoms, such as just fecal smearing for example, will often have relief.

And what I do is I actually do a manometry before, and a manometry about six to eight weeks afterwards, so that you can have objective data looking at the numbers that they actually got better, in addition to the patient symptoms.

The last thing I should kind of throw in there is that for incontinence itself, there’s actually somewhat of an indication these days for a combined incontinence and constipation, you can have a sacral nerve modulator put in. It’s kind of like a spinal cord stimulator device that you would use for back pain, that’s implanted into the iliac fossa in your back hip, and it stimulates the S3, S4 nerves to actually make the sphincters function properly. Those work very, very well as well.

Kevin Pho: So we opened up this conversation with you saying something like pelvic floor dysfunction isn’t as discussed as perhaps it should be. Why do you think that is?

Carmen Fong: I think it’s complex. And not just to be like, oh wow, I can discuss this super complex topic, but because it is so multifactorial. It can be lifestyle factors, it could be dietary factors, it can be anatomy factors, that it takes a lot of different perspectives to kind of come down to one diagnosis. A lot of it is rule out as well. But I would say it’s because it’s so multifactorial.

Kevin Pho: Over the course of your career as a colorectal surgeon, that awareness of pelvic floor dysfunction, have we moved the needle in that respect?

Carmen Fong: I think we have. So even in the major societies, at least in the colorectal societies, we actually have a pelvic floor symposium, where we are kind of trying to push the envelope in terms of like, oh, we need to look more into this, and more people doing ventral mesh rectopexies for example. But still, it’s like I would say a small percentage of even our society and of surgeons.

But I think the bigger factor is what you said, which is that primary care providers need to know what to look for and when to send for a referral, because there is some overlap of course, like you mentioned, colorectal surgery, gynecology, urology.

Kevin Pho: Do you see a future where there are going to be specialists in pelvic floor dysfunction that kind of focus just on this?

Carmen Fong: Yes I do. And I think it’s like one of those things where we keep subspecializing, subspecializing, until it’s like, oh, you’re treating like my left little toe. In the U.K. there actually are pelvic floor subspecialists. So I do think that we might eventually have, at least in the colorectal field, another year-long fellowship or a certificate of some sort where you can actually be trained to do this. They already do that for like breast ultrasound. So I imagine that there could be further training for anal manometry, for pelvic floor dysfunction specifically.

Kevin Pho: We’re talking to Carmen Fong. She’s a colorectal surgeon. Today’s KevinMD article is “Why pelvic floor disorders deserve more attention.” Carmen, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Carmen Fong: I would say if you are struggling, my main point is always go see a doctor about it. It’s OK to talk about poop, you know, everybody does it. And I think that people just struggle in silence for so long because it’s an embarrassing and taboo topic to talk about. But if it’s something where you’re like, I’m having trouble pooping, or I’m pooping too much, I’m pooping too little, it’s definitely worth an ask. And then as always, colorectal screening starts at 45, so go get your colonoscopies.

Kevin Pho: Carmen, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Carmen Fong: Thank you. All right, bye.