Focusing on Female Pelvic Floor Disorders

Dr. Susan Tate joins Hardin Memorial to create a multidisciplinary pelvic floor center

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ELIZABETHTOWN “Female pelvic floor disorders are ubiquitous,” says Susan Tate, MD, urogynecologist and reconstructive pelvic surgeon with Hardin Memorial Health’s Urogynecology Specialists. However, women with these disorders are a largely untreated population. Too often the mentality is that these problems are just a normal part of aging, and many women are uncomfortable even discussing their sensitive and somewhat embarrassing nature.

Newly employed by Hardin Memorial Health, Tate’s dream of establishing a multidisciplinary pelvic floor center is coming to fruition. Trained as a general OB/GYN in gynecologic surgery at a time when urology was dominated by men and urogynecology did not exist as a specialty, Tate pursued a fellowship in London, England, under renowned urogynecologist Stuart Stanton.

“My practice now is absolutely focused on all aspects of female pelvic floor disorders, encompassing the entire range from the simple to the highly complex,” says Tate. No longer practicing general gynecology, she has been careful to establish herself as a resource for managing recurrent or complex problems, not replacing the care of gynecologists or urologists who often refer to her.

A Shared Vision

To execute her vision, Tate needed the assistance of partners with similar expertise. Linda Blackwell, RN, is a nurse clinician with extensive experience as a patient educator and clinical researcher. In 2010, Tate teamed up with Rick Rayome, RN, who was one of the first to provide video-urodynamics in Kentucky to assess patients with complex incontinence and voiding difficulties. Additionally, she partnered with Dennis Shoff, MD, an Elizabethtown gynecologist whose surgical experience made him a good collaborator on complex cases. Hardin Memorial Hospital, with state-of-the art laparoscopic and robotic operating room equipment for minimally invasive surgery, also serves as an essential partner for Tate’s practice. She believes Hardin Memorial is a perfect fit because of their smaller size, approachable atmosphere, reputation for innovative thinking, and enthusiasm for the program. “Hardin recognized this was something no one else was doing. No one else is doing this in Kentucky on this scale. Hardly anyone else is doing this in the United States,” she says. Beyond her immediate partners, Tate also works closely with urologists, colorectal surgeons, general surgeons, gastroenterologists, and other specialists because so many of the diagnoses overlap.

Pelvic Floor Disorders and Treatment

The expanse of pelvic floor disorders covers anything pertaining to urinary complaints, prolapse, and bowel complaints. Bladder symptoms can include overactive bladder, urgency, frequency, and stress incontinence. Pelvic organ prolapse can affect the vagina, uterus, bladder, and rectum. Symptoms of prolapse include the feeling of a bulge, pressure, or something falling in the vagina. In addition, prolapse can alter the anatomy in a way that results in bladder and bowel dysfunction.

Many patients suffer from a combination of urinary issues and prolapse. The diagnostic process is critical in tailoring treatment to each individual. “We fit the operation to the woman, to her specific problems, to her specific complaints, and to her specific physical health otherwise,” Tate says. Diagnostic testing for urinary complaints may include urodynamics testing, cystourethroscopy, radiologic imaging studies, anorectal manometry, and defecography.

Treatment options vary from conservative behavioral interventions to medication therapy to complex surgical procedures. “Treatments we have now in terms of urinary urge incontinence and urinary frequency are infinitely better than we had before,” says Tate. In properly selected patients, two treatments that significantly impacts patients’ quality of life without the need for medication or major surgery are sacral neural modulation and posterior tibial nerve stimulation. Sacral neural modulation, a simple outpatient procedure, functions essentially as a bladder pacemaker implanted into the sacral nerve area to offer stimulation controlled by the patient. Posterior tibial nerve stimulation is another alternative procedure that provides stimulation to the bladder via the tibial nerve in the leg using a very small needle attached to an external stimulation device. This painless treatment is done in 30-minute sessions once a week for a 12-week period, after which many do not need further treatment or may need only an occasional booster.

Vaginal slings have revolutionized treatment for stress incontinence. What used to require major surgery with a large abdominal incision and hospital stay can now be done as an outpatient in 20 minutes under local anesthesia with sedation. Additional techniques utilized by Tate for stress incontinence include transobturator slings and intra-urethral bulking agents.

The most common procedures for Tate are combinations: prolapse and urinary incontinence or prolapse and bowel dysfunction, in which individualizing surgery and treatment are paramount.

“The gold standard for marked prolapse is sacral colpopexy,” says Tate, but it is a major surgery that may not be appropriate for every patient. Advancements in abdominal sacral colpopexy include laparoscopic and robotic surgery options. Tate acknowledges the recent controversy with vaginal mesh, but says abdominal sacral colpopexy falls outside those criticisms because this approach is not vaginal and not all grafts are synthetic.

In many cases the etiology of the prolapse is that the cervix or vagina has detached from the uterosacral ligaments. For a first or second repair, prolapse can be treated vaginally, laparoscopically, or robotically without graft material, synthetic or otherwise, by suturing the vaginal walls back in place. There are cases when a patient is not a candidate for surgery or desires more conservative options such as a vaginal pessary or pelvic floor biofeedback and rehab. Pelvic floor rehab, which is administered by a specially trained physical therapist at Hardin Memorial’s Therapy & Sports Medicine Center, can be very effective in improving patient symptoms.

New Board Certification

Access to urogynecologists nationwide is a challenge, as there are a limited number of these specialized practitioners. However, there is growth on the horizon. Tate is part of a group of urogynecologists and urologists who have supported board certification for the subspecialty of Female Pelvic Medicine and Reconstructive Surgery through the American Board of Medical Subspecialists. Its first exam will be administered in 2013.

I have always wanted to establish a specialized, multidisciplinary pelvic floor center focused on addressing these issues for women in a comprehensive manner, and our vision is to grow this service statewide.

FOR REFERRALS: Dr. Susan Tate, Urogynecology Specialists, 1310 Woodland Drive, Elizabethtown, KY 42701, (270) 765-6141.