Floor Plan

At the pelvic floor center, specialists take a unique holistic approach to pelvic floor anatomy and function to improve outcomes.

by Monika Guttman

There is a quiet revolution going on in medicine, and it involves parts of the body few people like to talk about, let alone seek to treat. It concerns the intricate series of muscles, ligaments and nerves that interconnect around the urethra, bladder, anus, rectum and, in women, the vagina—known collectively as the “pelvic floor.”

Traditionally, pelvic floor disorders such as incontinence have been segmented into specialties such as urology, gynecology and colorectal surgery. Howard Kaufman, M.D., associate professor of surgery and obstetrics and gynecology at the Keck School of Medicine of USC and chief of the division of colorectal and pelvic floor surgery in the Department of Surgery, and his colleagues are “leading the change to treat the area as an interdisciplinary whole instead of just the sum of its parts.” The result is the new Pelvic Floor Center at the Keck School of Medicine of USC, which Kaufman will head as director.

David Ginsberg, M.D., assistant professor of urology, and Claire Templeman, M.D., assistant professor of obstetrics and gynecology and surgery, are both members of the Pelvic Floor Center team. Ginsberg says, “My sense is that our collaboration is fairly unique. We examine patients together, we discuss the cases at a weekly meeting, and we even perform surgeries together. I do female urology but I don’t do gynecology, but Dr. Templeman does. This way we cover all the bases at once.”

Damage to the pelvic floor results from many causes. In women, childbirth can stretch and injure the pelvic muscles or anal canal. In men and women, aging, straining to have a bowel movement, obesity, infections, surgery and cancer can injure the pelvic floor.

As a result, women can experience organ prolapse—when a pelvic organ such as the rectum or the uterus actually protrudes out of the body. Or they may experience incontinence—the inability to hold urine or bowel movements. According to the National Institute of Diabetes & Digestive & Kidney Diseases, more than 13 million people in the United States—male and female, young and old—experience urinary incontinence. By the age of 80, one in nine women will have had surgery for the condition. About 10 to 13 million people in the U.S. have loss of bowel control—a condition that people are even less likely to discuss with their physicians than urinary incontinence.

Kaufman says he is a big advocate for change in the public’s perception of pelvic floor disorders. Until now, he says, “people just haven’t been comfortable talking about incontinence—so it doesn’t get serious consideration.” Growing numbers of aging Baby Boomers and cancer survivors “mean we need to get people educated that this is something treatable.”

One of his priorities, he says, is to “take away the stigma by offering compassionate, excellent multidisciplinary care, as well as access to the latest advanced therapies. The more we can educate the public, the less embarrassed they will be. It’s a part of aging, it’s a result of childbirth, it’s a result of our diet, but it’s something that is treatable.”

Ginsberg believes increased advertising for drugs that treat incontinence, as well as wider awareness among physicians, is helping overcome the stigma. “Ten years ago, this wasn’t a hot topic,” he says. “Now people are hearing it discussed on TV, they are bringing it up to their doctors, who are then looking at this as something treatable. That’s a start in the right direction.”

Often patients think they have one problem, when in reality they have several issues contributing to their discomfort. “A patient with urinary incontinence may not know that she has a prolapsed uterus that is contributing to her incontinence,” notes Templeman. “Given the imaging we can do of the entire area and several specialists looking at the same problem, we’re able to diagnose more thoroughly, which helps us pick up all sorts of problems that a single visit to a single specialist might miss.”

At the Pelvic Floor Center, the entire pelvic floor is treated as a functional unit. That means urologists, gynecologists, colorectal surgeons, radiologists and physical therapists are involved in each case, “so all possibilities are considered and all problems addressed,” says Kaufman, who was co-director of a similar center at the Johns Hopkins School of Medicine before coming to the Keck School of Medicine. “We believe that by taking a holistic approach to pelvic floor anatomy and function, we will be able to improve outcomes.”

Treatments for pelvic floor disorders have a notoriously poor long-term success rate, notes Kaufman. While at Hopkins, he participated in a study of women who had pelvic floor procedures and found the median number of previous procedures was three, and some women had as many as 11 separate operations. Kaufman says, “By breaking down traditional barriers and collaborating, physicians can look at what works on the diagnostic side and on the therapeutic side and make improvements.” For example, he notes, biofeedback and exercises work at least temporarily for 60 percent of patients who have pelvic floor problems, but long-term outcomes need more investigation.

A known, leading risk factor for pelvic floor dysfunction is obesity. “For many people, incontinence is dependent on the amount of pressure on the pelvic floor. If you reduce the pressure through weight loss, the symptoms may get better and eliminate the need for surgery,” Kaufman says. Surgeons at the Pelvic Floor Center are studying symptoms in patients before and after weight loss to determine the effects weight has on pelvic floor health and dysfunction. “If someone’s been overweight for 40 years, is the damage done? Or will the symptoms get better after weight loss? We have the opportunity to find out,” he says.

Women also may need strengthening exercises or relaxation of spastic muscles to improve bowel and bladder function. Julie Guthrie, D.P.T., in the Department of Biokinesiology and Physical Therapy, works one-on-one with patients to develop and execute a physical therapy plan, either as a primary method or in addition to surgery.

Technology, too, is improving diagnosis and treatment for pelvic floor problems. The Pelvic Floor Center has one of the few three-dimensional ultrasound machines in the country; it is used to diagnose patients with incontinence, chronic anal infections or anal or rectal tumors. Suzanne Palmer, M.D., assistant professor of clinical radiology and medical director of radiology at USC University Hospital, leads the compassionate team of technologists and specialists who work with patients as they undergo special MRI and X-ray studies.
“A classic sonogram does not show the entire anatomy of the anal canal, so we would operate without knowing the exact length,” Kaufman explains. Being able to see the entire anal canal with the 3-D images “means we can look at the disruption that has occurred and spare surrounding tissue because of our improved ability to better define the anatomy going into an operation.”

The Pelvic Floor Center team also specializes in clinical trials of minimally invasive procedures and technologies to solve pelvic floor disorders. One example is sacral nerve stimulation, an effective treatment alternative for people who suffer from urinary retention problems and symptoms of an overactive bladder, such as urine leakage that occurs when there is a strong urge to go to the bathroom. Kaufman explains that a neurostimulator about the size of a stopwatch is implanted near the sacral nerve in the lower spine. It sends small, electrical impulses to the sacral nerve that controls voiding function because the constant stimulation improves continence.

Kaufman adds that since bowel function and continence improved in many women who have the stimulator implanted for urinary incontinence, he is now enrolling patients in a trial to study sacral nerve stimulation in those with bowel control problems.

Another trial involves radiofrequency energy treatments to the anal canal for fecal incontinence. “After the patient is appropriately sedated and has received a local anesthetic, a probe is put inside the anus to heat the tissue underneath the lining of the anal canal. That forms scar tissue, which bulks the outlet and prevents incontinence,” Kaufman says. “So far, it is a fantastic alternative for patients who have exhausted surgical options or who have not had success with biofeedback.” The procedure is performed on an outpatient basis at USC University Hospital.

Ginsberg, too, offers the latest in medications and minimally invasive surgical procedures to treat urologic incontinence in men and women. For women, a common problem is so-called “stress incontinence”—where lifting, sneezing or coughing can cause pressure on the urethra and push out urine stored at the base of the bladder. “The traditional surgeries like a pubovaginal sling are major operations,” Ginsburg notes. New minimally invasive techniques “allow us to approach the problem vaginally, so women can go home the same day. It means far fewer difficulties, and ultimately the outcomes are as good or maybe better than with some of the older procedures.”

One of the new techniques offered at the Pelvic Floor Center is TVT, or Tension-free Vaginal Tape, a procedure pioneered in Europe in the mid-1990s. Through a small vaginal incision, Ginsberg places a small, mesh-like tape underneath the bladder neck. The tape then supports the bladder, preventing stress leaks. The outpatient procedure usually requires only a few days for recovery and, in studies so far, has worked successfully for 80 percent of patients.

Ginsberg offers another new procedure, the SPARC Female Sling System—a minimally invasive system for placing a sling to support the urethra through two small incisions above the pubic bone. The SPARC, TVT and other minimally invasive operations now in clinical trials reduce the time needed for recuperation and are being studied for their long-term efficacy.

Templeman believes the collaborative aspect of the Pelvic Floor Center will appeal to many people who would otherwise shy away from seeking treatment. “We’re trying to avoid what has been the typical scenario until now—one operation for the uterus, then another for the urethra or for fecal incontinence,” she says. “Many people would put that off, because it was too much to consider. By combining it under one roof, with one team of physicians, we can offer people the advantage of dealing with it in one procedure.”

Members of the Pelvic Floor Center understand that treatment can help patients face the future more easily.
“All of the pelvic floor procedures we offer are designed to improve quality of life,” Kaufman says. “We want to help free affected individuals from significantly altering their lifestyles—some to the point of being housebound. There is no need for that kind of disruption, and we are trying to help people understand that there are alternatives that work.”

For more information about the Pelvic Floor Center, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).