Bladder Cancer Treatment Options

(announcer)major funding for second opinion is provided by the blue cross and blue shield association,an association of independent, locally operated, and community based blue cross and blue shieldcompanies, supporting solutions that make safe, quality, affordable healthcare availableto all americans. second opinion is produced in associationwith the university of rochester medical center, rochester, new york. (music) (dr. peter salgo)welcome to second opinion where you get to

see firsthand how some of the country’sleading healthcare professionals tackle health issues that are important to you. now, each week, our studio guests are puton the spot with medical cases based on real life experiences. by the end of the program, you’ll learnthe outcome of this week’s case and you’ll be better able to take charge of your ownhealthcare. i’m your host, dr. peter salgo, and today,our panel includes, dr. gunhilde buchsbaum from the university of rochester medical center;special guest, sherrie palm; physical therapist, dr. wendy featherstone; dr. victoria handafrom johns hopkins; and our second opinion

primary care special physician, dr. lou papafrom the university of rochester medical center. our case today concerns lisa. she’s a 44 year old woman, a daycare worker,married with two children of 18 and 15 years. she’s in her primary care physician’soffice now for a routine medical follow up. after discussing the results of all of herlab work, all of which by the way, were normal, so no need to go further with that, exceptfor her thyroid test. she’s known to have some thyroid issues. her pcp adjusted her thyroid dose and askedher if there is anything else she would like to talk about.

her reply was, “nope. everything’s fine.” is this common? lou papa)yeah, it’s common. if you have a young healthy person, it’snot unusual that they don’t bring anything up, that’s why very often we’ll ask toreview a systems questions. peter salgo)review of systems is? lou papa)review of systems is a way of prodding the patient’s memory a little bit.

so, we usually go over the different systemsin the body. neurologic system, cardiovascular system,asking them about specific symptoms they have been experiencing that are bothersome or affectingtheir quality of life. some stuff, patients don’t want to talkabout. peter salgo)i read ahead in the chart a little bit and i happen to know that she’s not tellingher primary care physician something very important. she’s been feeling pelvic pressure and she’sbeen having trouble keeping a tampon in place and further, she’s disturbed because sheand her husband have been drifting apart.

she’s been having pain during sexual intercourseand so they haven’t been engaging in sexual intercourse, so they haven’t been engagingin sexual intercourse. does it surprise you that she didn’t sharethis? lou papa)unfortunately, no, it doesn’t surprise me. those are very sensitive topics for both menand women and very well depends on trying to tease it out a little bit. peter salgo)but i mean, it’s a doctor’s office. if there’s any place you’re supposed todeal with this, isn’t it your office? lou papa)it is, but i mean if you can imagine just

talking about those sorts of things are embarrassing. in some respects, your primary care doctor,you have a long term relationship, you know, people don’t even talk to their family membersabout this stuff and sometimes, the primary care doctor is almost like a family member. they are just embarrassed in talking aboutit, especially if it’s affecting the relationship of the spouse. peter salgo)well, two years go by after this doctor visit, during which she shared none of that informationand now, she’s in her obstetrician’s office and she’s been experiencing lower back pain,pelvic pulling and she often feels that when

she’s sitting, she’s sitting on a ball. she’s terrified, she says, because she alsohas noticed something sticking out of her vaginal area. so, we’ll broaden this discussion to everybodyon the panel. what’s going on here? gunhilde buchsbaum)she has pelvic organ prolapse. peter salgo)you think its prolapse? what is that? gunhilde buchsbaum)prolapse is when the pelvic organs, which

include the uterus, bladder and vagina, aresagging from their normal anatomical position. the most common symptom that a woman experienceswith pelvic organ prolapse is feeling a bulge from her vagina, often when they are wipingthemselves or washing themselves. peter salgo)so, this is a common presentation that they are experiencing. what holds the pelvic organs in place? gunhilde buchsbaum)well, connective tissue of all types. the vagina by in large is suspended sidewaysin front, back and towards the top by various connective tissue structures.

in addition, the pelvic flow muscles givesupport to the pelvic structures. peter salgo)so, these pelvic organs are held in place by structures and you get a model to showus exactly what we’re talking about here. wendy featherstone)yes, the pelvic floor muscles run from the pubic bone in the front and back to the tailbone. they’re kind of like a hammock or a slingthat helps support the pelvic organs. they’re also helped by some of the hip musclesfrom the side and are part of the core muscles, which many people think are just abdominalmuscles. so, in terms of back pain, you think of thisas sort of a functional unit.

you have the pelvic floor and the core musclesthere. peter salgo)so, in terms of this prolapse that we’ve been talking about, is it fair to say thatthe muscles aren’t doing what they’re supposed to be doing here? gunhilde buchsbaum)i don’t think we can isolate the muscles or the connective tissue at just the one structure. they work as a unit. peter salgo)alright, well sherry, you’ve experienced this problem.

tell me your story. (sherrie palm)well, for me, the tissue of the vagina was what i noticed first. now, backdrop for me, i’ve been digginginto health issues of all different types for 25+ years. my best friend is my health care practitioner,so we had discussed all kinds of health issues on an ongoing basis, which made it even morestartling to me to find out when i went in to find out what that bulge of tissue wasthat it was pelvis organ prolapse, something i’d never heard of.

i had one vaginal delivery and i was 35 wheni gave birth to my son and there were no complications. he was 6 lbs. 11 oz., so he wasn’t a largebaby. i have ms and so i have a pre-dispositionto muscle weakness. i don’t have any problems with it. i’ve been very aggressive with my own regimento keep that under control. i am an aggressive exercise person and noidea that i really had to be concerned about pelvic organs. i did have a hysterectomy and that was a vaginalor abdominal incision. no complications from that, so one of thethings that probably compounded my personal

situation was that i’m very aggressive withmy landscaping and we have large boulders and when the front end loader wouldn’t pushthe boulders where i wanted them, i would use my body strength. peter salgo)can i just stop you for a minute? you had this big machine, this front end loader,it didn’t work, you were going to push it? is this a typical story, by the way, of someonepelvic organ prolapse? victoria handa)yeah, i would say that a lot of aspects of your story are typical and a lot of times,i don’t know how you felt, but a lot of times people notice something that looks likea lump and their first thought is that it’s

cancer, they have a tumor. so, sometimes people are really concernedon that basis before they find out what the cause is. (sherrie palm)that is where my thoughts went when i felt the bulge. i probably felt the bulge for about two monthsbefore i actually got a handheld mirror out and took a look to see. peter salgo)why did you take that long? were you frightened?

(sherrie palm)no, i wasn’t frightened at all; i just work a lot of hours. i was busy, you go in, you go to the bathroomand then you get on with your day. so, when i finally thought, “what is thatdown there?” i got the mirror out and i looked and i thought,okay, this can’t be good. it wasn’t painful. i just knew it had to be explored and i hadto find out what it was. peter salgo)okay, so we have a woman whose had some pelvic surgery, who’s had childbirth, vaginal delivery,does this tell you, is this the cause of pelvic

organ prolapse? can you point to those things and say, “that’swhat did it!” gunhilde buchsbaum)no we can’t. peter salgo)why not? gunhilde buchsbaum)because we know there are women who have had any children and they will have pelvic prolapse. we know women who had six, seven or eightchildrens, big ones on top of that, and they don’t have any pelvic organ prolapse atall. so, it seems that there is a pre-dispositionthat is biological towards prolapse.

when you have that, there might be additionaldamage or this might be worsened by giving birth. peter salgo)i’m going to tell you about lisa. lisa has had two babies, one 9 lbs. 7 oz.,the other 8 lbs. 5 oz., both were delivered vaginally. the first was delivered with the use of avacuum extraction, which i am going to simply suspect is a bit more traumatic than a non-vacuumextraction. she is 20 pounds over her ideal weight, shenever smoked, she’s experienced occasional stress incontinence for the past fifteen yearsand she’s been noticing it more and more

recently, this prolapse, when she lifts kidsat the daycare center where she works. any of these things sound like a risk factor? victoria handa)there’s a lot of things in there that could be a risk factor, i mean i definitely agreewith gunhilda that there’s probably some inherent biological pre-disposition that somewomen have towards this problem, exactly what that is, we need to find that out. i would disagree a little bit because i thinkchild birth is a very powerful risk factor. there is no question that there are womenthat have not given birth who develop prolapse regardless, but having had a vaginal deliveryis a huge risk factor, but i think a little

bit more problematic and controversial aresome of the other things you mentioned. obesity, not clear that that’s a risk factor,may be, and i think that even the heavy lifting is a little bit controversial. lou papa)it’s just like any other disease, there are certain risk factors that are very strongand some that are not quite so strong, but there are individuals that have heart diseasethat do all of the right things and don’t have any of the risk factors. peter salgo)okay. wendy, what about kegal exercises?

would they have helped? wendy featherstone)a lot of that depends upon the degree of the prolapse. with a milder prolapse, less bulging out,you can use exercises to help reduce the symptoms. now it doesn’t repair the connective tissuethat gunhilda was speaking of, so if we think about it, it’s not just the kegal exercises,it’s not just the pelvic floor because you want to think also, in lisa’s case, aboutwhat she does during the course of the day. you want to look at her posture. we look at alignment things as physical therapists.

how do you keep the rib cage lifted off ofthose organs? how we’re using the muscles that work withyour pelvic floor/? your pelvic floor is part of the core, asi mentioned a little while ago and it works with the deepest layer of your abdominal muscles. so, if you’ve got some muscles, some ofthe bigger abdominal muscles, have the capacity to actually fold you forward and push downward. it’s a balance of or a coordination of thesemuscles that we’re looking for. other things, in lisa’s particular caseis her lifting. we take a look at how are you lifting?

are you bending over and straining to liftthe children in your daycare, and taking a look at teaching her proper body mechanics,how can you avoid pushing down from above, as well as let’s lift up from below andaround, and get good postural support. peter salgo)well, the doctor does a pelvic exam on lisa and finds that she as a prolapsing cystocele. what’s that? gunhilde buchsbaum)so, the bladder rests on the top part of the vagina and when that starts sagging, it iscalled a cystocele as opposed to when the back part is sagging, or the support is weakenedand the rectum starts bulging, that is a recto

seal. peter salgo)so, there are different kinds of prolapse. do they all have the same symptoms? gunhilde buchsbaum)they have some in common, a bulge is a bulge. just when somebody feels a bulge, it meansto me there is a prolapse, but i couldn’t tell from a bulge what that bulge is. peter salgo)are these symptoms that women experience life altering? gunhilde buchsbaum)some can be.

some women have no symptoms at all, some womenhave mild symptoms only, others might not be able to void, some women have to push backthe prolapse in order to urinate or to move their bowel. some women have pain. what about with you? did it alter your life? (sherrie palm)i’m one of the fortunate ones that did not have pain with my prolapse. the thing that impacted me the most, i wouldsay, was i was a grade three.

i had three types of pop out of the five types. in a more advanced stage, it’s not an incontinenceissue which is very common in the earlier stages. its urine retention, you can’t get the peeto come out. that was the part that impacted me the most. peter salgo)wendy, you see women with this problem, what’s the most common complaint you see? wendy featherstone)they do come to me with the complaint of the bulge.

usually it’s worse as the day wears on. they get to where they don’t want to standtowards the end of the day. it’s kind of a fatigue factor by the endof the day. difficulty lifting and intercourse can bea problem too, symptomatically. peter salgo)well, lisa, she says, “doc, did the size of my babies and my difficult labor causemy problem?” and your answer would be? gunhilde buchsbaum)i don’t know. wendy featherstone)i don’t know.

peter salgo)great. i’m sure lisa was really happy hearing that. would this have happened, she asks, if i hadhad a cesarean section? gunhilde buchsbaum)maybe. peter salgo)oh, this is even more definitive. victoria handa)well, we’ve just finished some research at johns hopkins to essentially look at thatquestion. the question is how much less risk do womenface regarding prolapse if they have a cesarean delivery?

our data suggests, now it’s hard to saythat this is the cause and effect, but for every seven vaginal births, there would beanother case of prolapse, so hopefully that would put it into context in terms of therisk. peter salgo)let’s talk about the overall incidents? how common is this problem? gunhilde buchsbaum)that is hard to say definitively because we just said; this is something that is not reallytalked about. most women who experience this problem arepost-menopausal. (sherrie palm)i beg to differ with that.

peter salgo)the numbers don’t support that? (sherrie palm)i speak with women every day and you read over and over that it’s women over 50 andi’m sure it’s the same for all of you ladies. i speak with women every day in their 20’s,late 20’s and up, the youngest one that i’ve spoken with is 21 years old, has nevergiven vaginal birth and never even given birth at all, a gymnast. victoria handa)i believe the average age for surgery is 50. peter salgo)its 50?

so it’s peri-menopausal? i guess they don’t come to surgery withoutsome symptoms persisting for some time and that common conception is wrong as well. so far, we’re just debunking everythingabout pop (pelvic organ prolapse). after the doctor told lisa that she had pelvicorgan prolapse, lisa said, “what on earth is that?” so, why does it seem that women are findingout what pop is only after they are diagnosed? why don’t more women know about it up front? lou papa)well, it’s probably the classic situation

where they’re kind of suffering in silence. a lot of times, if i find out about it, it’sbecause i’m doing a pelvic examination for some reason and they’ll say, “oh yeah,that’s been there for years.” (sherrie palm)these are topics that women aren’t comfortable talking to their doctors about. they can’t even talk to their husbands aboutthis stuff. everyone thinks that urinary incontinencestands alone, it’s a disease and it’s not, it’s a symptom. so, then you add in incontinence and if youadd in the pain with intercourse and the tissues

on your vagina. women that i speak with that are shying awayfrom sex because of the symptoms and let me ask the men on the panel here. if your, the woman in your life, and you havehad a healthy intimate relationship with her for “x” number of years, suddenly stoppedbeing intimate with you. would it occur to either of you that therewas a health condition related to that or would you jump right to the whole, “eithershe’s not into me anymore or she doesn’t enjoy sex anymore page.” peter salgo)lou, you can handle this one first.

lou papa)well, it’s kind of unfair because i have a medical background, so i would be concernedto some respect that if it’s suddenly stopped like that then it would be a medical cause,or there’s something physiological or depression or something like that would be raising that,but i would agree with you that if that happened in some other instance without that kind ofhook in knowing that it probably would create a lot of tension. peter salgo)okay, i would like to pause for just a minute and sum up where we are. pelvic organ prolapse is a condition thatoccurs when the normal support of a vagina

is lost. the result of which is that the pelvic organsand the tissues sag downwards. the symptoms often create a scenario of embarrassment,as well as discomfort, patients often don’t talk about it and as a result, a lot of womendon’t even know about it. lou papa)i think it’s important, like any of this kind of “taboo” topics that nobody wantsto talk about, there’s always a concern that it could be something more serious. i know a newer degenerative disorder comesinto mind. there’s a collection of abdominal sidingsor masks that could be growing that could

be exasperating the problem, so it is somethingthat warrants investigation. there is some danger in not reporting it. peter salgo)alright, well we started off this broadcast talking about lisa, who’s been experiencingpelvic organ prolapse and sharing her story with us is sherry. lisa is referred by her obstetrician to auro-gynecologist. what’s going to happen there? gunhilde buchsbaum)first we take a history, so i ask her how she is aware of it.

i ask her whether she has any problems emptyingher bladder, whether she’s experiencing urinary urgency, whether she needs to useher finger in order to evacuate her bowel, whether she has any other symptoms. peter salgo)these are very embarrassing questions. gunhilde buchsbaum)that is true. it is very important that as a physician,you make your patients feel comfortable to answer these questions. peter salgo)alright, well lisa has been diagnosed with a cystocele, what are her treatment options?

surgical, non-surgical, help me out with this. victoria handa)well, other than the physical therapy, another non-surgical option to consider would be apessary. peter salgo)what is a pessary? victoria handa)a pessary is a device that goes in the vagina, the woman can put it in herself and take itout in most cases, and it basically just supports the walls by holding up on the walls. pessary isn’t necessarily the answer forevery woman with prolapse. some women, depending upon their anatomy,might find a pessary uncomfortable.

it may not stay in position well. if women are motivated to try a peccary, it’sworth a try in case it’s the perfect solution for them. peter salgo)the surgical options are what? gunhilde buchsbaum)well, for the cystocele right now, again, surgery depends very much on what the exactdefective prolapse is. now in my opinion, i rarely see the cystoceleall by itself. most of the time, a cystocele comes togetherwith a dropping or a sagging of the uterus. so, most women who undergo a surgical repairfor a cystocele need some kind of support

of the top of the vagina, also. peter salgo)sherry, what course of treatment did you pick? (sherrie palm)well, initially, i tried the peccary, that was the second term that i got from my physicianthat i’d never heard of before and i tried it for a couple of weeks and i’m lucky thesecond one she fitted me fit great. i had no discomfort. i learned the insertion/removal quickly, however;after two weeks of utilizing the pessary, i knew it wasn’t going to work for me becauseit’s just one more thing to do. when you’re a busy person, when you’rea busy woman and you’ve got to do all of

the other things in your life that you’vegot to care of, this was one more thing to stack on top of it and i just didn’t wantto deal with it, so i shipped it to surgery. peter salgo)well, lisa tried the pessary and in fact it worked for her for two years, but two yearslater, which is where we are now, she’s back to see her uro-gynecologist, she saysthat she just can’t find the time to do the peccary. she’s supposed to do the kegal exercises,but she can’t do them. although she’s happy with peccary, she wantsa more permanent fix. after examination, her doctor finds that herprolapse is worse, so lisa wants surgery.

if she has the surgery, will she be fixed? gunhilde buchsbaum)potentially. again, i tell my patients that the greatestrisk of surgery for prolapse is occurrence for prolapse. that’s the number one risk. how big that risk is between ten and thirtypercent and forty percent, it depends. also, if we fix what is broken now, that isno guarantee that something else that is not broken now will not break later. this is sort of a weakness of the supporttissue of the vagina and often is something

is weak, everything around it might be weak,too. peter salgo)that being said, let’s stop for a minute and sum up what we’ve discussed so far andthen we’ll continue on again. management for pelvic organ prolapse may beexercise or it may be devices or it may be surgery. the course of treatment depends not only onthe anatomy and the severity of the condition, but on the individual as well. it is important to know that no matter what,there is something that can be done to improve the condition.

this is not a hopeless case. there is lots of opportunity for treatmentout there. well, lisa’s happy. after having the surgery, she has no longerhad her tissue bulging out, but she was surprised to find that her bouts of stress incontinencedid not go away and she is still experiencing painful intercourse, so the surgery didn’tfix everything. why not? victoria handa)well, i think, like sherry said earlier, sometimes incontinence and prolapse are related andsometimes they’re unrelated.

typically, it’s not that uncommon that they’reseen in the same patient, so i would typically assess a woman for incontinence if she waspresenting with prolapse, so they could both be addressed at the same time, but a treatmentfor prolapse won’t typically cure incontinence. the one that’s a little harder, though,is about the discomfort with sexual activity. some of the symptoms we’ve been talkingabout are not specific to prolapse, so discomfort with sexual activity, back pain, there’sbeen some other things that have come up that may or may not be related to prolapse at all. peter salgo)going forward in terms of her physical activity, what she can do to help herself, what do yourecommend for her?

wendy featherstone)well, as gunhilde mentioned, the chance of this recurring is a problem and so doing exercisein adjunct to the surgery is, you know, the surgery isn’t the quick fix. so, to have her say, “didn’t have timefor the kegals. couldn’t do them.” you know, you have to make time, its maintenance;it’s what you’re going to have to do. then thinking about, okay, so what else mightbe helpful there strengthening wise, she’s lifting kids all day. very often with surgeries, there’s a liftingrestriction for a period of time, but my opinion,

when you’re strengthening, you’re actuallygoing to prevent strain, so the stronger you are, you lift that kid up, you can do it,then you aren’t straining and pushing down and pushing out your organs. so, you really want, you know, good muscularstrength throughout the body as a preventative, as an adjunct to the surgery, so i think she’sjust going to have to find the time for that. lou papa)the therapy that is prescribed is like another prescription. it’s like saying you don’t have time totake your blood pressure medication. a lot of surgical procedures, joint replacement,cardiac surgery, the trip up in recovery very

often is falling behind on the therapy. peter salgo)sherry, how you doing? (sherrie palm)i’m doing great. i’m a big believer in maintenance. if you want to maintain the best quality oflife, you have to do maintenance and whatever form works for you, so the kegals are so importantand i’ll be doing those until i’m dead. as far as i’m concerned, the most importantthing we can do is to create the recognition of this health issue and let women know thatthere’s no stigma tied to pop, no matter what symptom you’re experiencing.

once we get the symptoms on the table, everybodystarts talking about them; it’s going to be the same path as what happened with erectiledysfunction twenty years ago. nobody talked about it twenty years ago, nowit’s on prime time tv. so, the same thing needs to happen with this. once women are familiar with this condition,they know what the symptoms are, they’ll recognize those symptoms in themselves, andthey’ll go to their physicians and they won’t be so embarrassed to ask the rightquestions and get the help that they need. peter salgo)that is all the time we have for this broadcast. thank you so much for coming, thank you all.

we are out of time, but you can continue thisconversation on our website secondopinion/tv.org, where you’ll find transcripts, videos andmore about pelvic organ prolapse and other healthcare topics. again, thank you for watching, thank all ofyou for being here, especially you, and i’m dr. peter salgo, and i’ll see you againnext time for another second opinion.