“Sophie, a hospital practitioner in the urology and kidney transplant department at the Georges Pompidou Hospital, a specialist in pelvic statics, talks to us about the power of the taboos surrounding these pathologies and the importance of coming for a consultation as soon as possible.”

Anna: Hello Sophie! So, I'm delighted that you accepted my invitation to participate in this podcast. I'll start by letting you introduce yourself. Your name is Sophie Hurel.

Sophie: My name is Sophie Hurel, I am a hospital practitioner in the urology and kidney transplantation department at the Georges Pompidou European Hospital. I am also a member of the Curopf committee for female urology and pelvic perineology, which is referenced by the French Association of Urologists, and I deal more specifically with what is called pelvic statics, that is to say urinary incontinence and prolapse (organ descent). So, this is a bit of a sub-specialty in the department, even though I also do a bit of oncology.

A: In this specialty, whether it's urinary incontinence or prolapse, do you only see women?

S: Exactly, in my consultations, I have 80% women. I think there's a little bit of the fact that women, ultimately, when they have this type of pathology, they prefer to see a woman because they have the impression that they are better understood, not judged. In any case, it worries them less. And then, it touches on the intimate, the clinical, gynecological examination, so it's true that I have the impression that women prefer to see women. Not necessarily rightly, of course, because a man is quite capable of doing this specialty. From the moment we are doctors and we wear a coat, we are neither a man nor a woman.

A: Yes, when talking about this somewhat irrational side of choosing a woman as a doctor when it comes to incontinence, the idea was to really show that it touched on a taboo.

S: Exactly, that's why I agreed to do this podcast because we have to fight against the taboo. And I still feel like today, even if it's really starting to change because women's magazines are starting to talk about it, we see ads on TV for diapers, so it's becoming a little less taboo, but ultimately when it affects you, it's still a little shameful. Because we may be afraid of smelling like urine. It's still something that hurts women and makes them ashamed, in fact. And that's why we absolutely have to talk about it because there are solutions. There are solutions that adapt to each patient, solutions that aren't necessarily surgical or at least not necessarily surgical straight away. So, that's why you also have to come see us fairly quickly before you have catastrophic leaks. Because here, it's true that the solutions are necessarily a little more surgical. In any case, just because you go to see a surgeon doesn't mean you're going to have an operation. So I think you really need to come and see someone quickly, talk to your GP and fight against taboos because there's no shame in that. Everyone has the right to have the pelvic life that suits them and that they want.

A: That's great because you directly delivered the message that was close to your heart! We know each other a little in our informal lives and you really wanted to be interviewed because you told me "I want everyone to know"

S: Exactly, in fact, it's a specialty that is very interesting compared to cancerology. Cancerology is very interesting, but ultimately, when you treat cancer, there are what we call guidelines, which are recommendations. Basically, we know roughly what we have to do: for each situation, there is a given solution that is the same for everyone. Pelvic statics, in my opinion, is much more interesting, because it's the situation that adapts to the patient; there is a personalized solution for each patient.

A: What you're saying is really interesting, and then I know you're going to address the issue of quality of life, the trade-offs that need to be made to adapt quality of life to the patient's clinical situation. And before that, I'd like us to go back to the beginning: urinary incontinence and prolapse, that is, organ prolapse. What is it? Which populations are affected by this type of pathology?

S: So, the prevalence is enormous. Prevalence is the incidence rate, it's the number of people affected in the population. It's enormous. Stress urinary incontinence is urinary incontinence when coughing, exercising, jogging, or using a trampoline. To give you an example, trampoline urinary incontinence affects 80% of women. As someone who has had children, if I use a trampoline, I might have a little leak. So, in fact, this prevalence is very underestimated, but basically, stress urinary incontinence, which is a problem due to the sphincter being less effective, is urinary incontinence, more likely in young women; it's about 15% of the female population. It's enormous.

A: These women might seek help because the disorder is sufficiently established and bothersome.

S: Actually, she needs to consult when it's embarrassing.

A: Okay, before we don't come, because we don't do trampolining every 4 mornings?

S: Absolutely, if you don't do trampolining every morning, and it's not bothersome, you don't need to consult a doctor. So, in fact, what you really need to do is consult a doctor when you're bothered. On the other hand, what you need to explain is that the perineum is an extremely powerful muscle, it's also the keystone of our body. You have to imagine the perineum like a church arch. Animals that have four legs don't have prolapses; we have prolapses because we're standing, because we walk on two legs.

The perineum is a muscle, so when you start to have very small leaks, you need to do rehabilitation that will strengthen the perineum. This will of course prevent prolapses and improve continence. And this rehabilitation must be done for all patients.

A: For those who have had children, it's quite easy to imagine leaks because they have had perineal rehabilitation, so they see more or less what it's like and they may be able to repeat the movements on their own.

S: That's it, too. There are a lot of patients who do their rehabilitation, especially their postpartum rehabilitation, and then don't do anything afterward. But it's exactly the same principle as the gym: that is, if you do sports two months before summer to get rid of your belly, to build muscle, get rid of cellulite, you'll look good in a swimsuit. But if you stop everything in September, it'll come back. It's the same thing with urinary incontinence. When you've had your 15 to 20 physiotherapy sessions, you have to keep doing the exercises at home, otherwise it'll come back! It's maintenance, just as you maintain your abs, you also have to maintain your perineum because your perineum is what supports us when we walk.

A: And then there is one last thing, which is the issue of incontinence due to overactive bladder, which is a completely different issue.

S: And in fact, we must not be mistaken because there are two main types of incontinence. There is stress urinary incontinence, which we just talked about, and overactive bladder urinary incontinence. This is urinary incontinence that generally appears much later in life, in the absence of neurological disorders. This is urinary incontinence, more common in postmenopausal women, with a prevalence that also increases with age, because the older you are, the more you have it. But it's about 25% of women from the age of 65, so that's huge too.

A: And we know what it is due to?

S: It's truly multifactorial. In fact, the first cause we can combat is the trophic disorders of menopause. In fact, at menopause, the hydration of the vaginal mucous membranes changes, and therefore we have vaginal dryness, which then creates changes in the vaginal, bladder, and intestinal microbiota. All these small changes can lead to overactive bladder.

What is overactive bladder syndrome? This is what we call urgency, when you have the urge to urinate you have to go right away, and you don't have time to hold it in with a reduced safety interval. Polacuria, that is, going to urinate often during the day, with more or less leakage, because we see that there are patients who have leakage in the syndrome and others who don't.

A: You gave me a very telling example: there are women, since the cafes have been closed, who can no longer leave their homes because they cannot imagine going to urinate when they need to.

S: Exactly, I have a lot of patients who had a real problem when the cafes closed because of Covid. Because they organized their walks around the toilets they knew. As a result, life is organized around the toilets. They no longer went out because they said to themselves: "if I ever have to urinate in the street, well, it's not possible." And what's more, while stress urinary incontinence is generally small volumes, 3-4 drops, overactive bladder, when you have a real leak, can be a complete urination. So, in fact, you're soaked. The symptoms are really different for these two types of incontinence. And the treatments we can offer are diametrically opposed.

A: And I also imagine that, as is often the case in medicine, it is never completely black or white and that there can be different types of incontinence in the same person.

S: Exactly. When someone has stress urinary incontinence without any other symptoms, we talk about pure stress urinary incontinence. As for overactive bladder syndrome, I've already explained it to you. But unfortunately, there are a lot of women who have a little bit of both. And so, that's the gray area, that's the difficulty. Like a lot of urologists, I try to conduct a good police interview, because it's a real investigation. It's a consultation that must, therefore, last a long time because we have to determine the type of incontinence that bothers your patient the most. And I tend to treat this type of incontinence first and then see what remains.

A: So here, we're going to return to a topic you touched on at the beginning, which is the question of treatment and surgery. Before surgery, I imagine you ask patients to go to physiotherapy.

S: It's worse than that. Certainly, now there's a kind of bashing about prostheses and prostheses that treat stress urinary incontinence. We all saw the Special Envoy on the subject with prostheses that are currently banned in England, in Anglo-Saxon countries. So, there's a real fear about that. And so, in any case, every patient before surgery must have physiotherapy. It's medico-legal. Okay, so physiotherapists haven't finished their work.

A: So there is a first phase.

S: Yes, it's 15 to 20 sessions. The physiotherapist determines the number of sessions. If, at the end of these sessions, the physiotherapist says: "I'm at the maximum of what I've been able to recover, of contraction." And then, two solutions. We still adapt to the patient, or she says "I'm really fine, I'm much better since I did physiotherapy, I've really become aware of my perineum because that's also there. The perineum, some people don't know what it is.

A: By the way, you could say it again, what is the perineum?

S: The perineum is your keystone. It includes the bladder, the vagina, therefore the cervix, the uterus and the rectum. And so, there are patients who don't know, don't know their perineum. There are patients, for example, when I examine them, we do what we call perineal testing, a vaginal examination. And I ask them to contract against my finger, I have patients who push. It's called a command reversal. And even you, if I ask you, "Cas-y, contract your perineum there"

A: So I don't know, but I think I don't do it too badly because it's one of my obsessions. When I'm sitting on the subway, I do it.

S: Thanks to that, you'll never need me. That's why we really need to do preventative work on the perineum, and I don't think it's said enough. And I also have the impression that there are quite a few obstetrician-gynecologists who, once they've done their work, ultimately don't insist. This isn't work we do three days postpartum, it's more like 6 months to a year after giving birth.

A: Do the risks related to the perineum begin from the moment you give birth?

S: Childbirth and obstetric trauma, that is to say, either difficult deliveries with forceps, episiotomy where you have to cut a little of the perineum, or very explosive deliveries, or patients who gave birth very, very quickly, and as a result, the child left like a bomb. These deliveries are inevitably damaging.

A: But a woman who hasn't had children, unless she's a top athlete...

S: Exactly, young patients who, for example, do hurdles, may have stress urinary incontinence, or patients who are very obese. Their perineum has to support all the excess weight.

I'd like to come back to obesity because there are factors we can influence and others we can't do anything about. Obesity, which is worsening in the general population, is a real factor in the aggravation of stress urinary incontinence. And we still need to tell patients that if we reduce their weight by 10%, we can reduce leaks by 50%. So, for obese patients (with a BMI – body mass index – above 35), we really need to try to make them lose weight before operating on them because it will improve their incontinence. It will improve all the other cardiovascular and joint factors. And what's more, we know that obesity is a risk factor for surgical complications and treatment failure. So, we need to try to make them lose weight before offering them surgical treatment.

A: So, if I come back a little to what was said, basically, you insist a lot on prevention, that is to say not going to consult once the disorders are proven, established, present for a long time.

S: I insist on the fact that if the problems are proven, you should above all go see your doctor, but if it is possible before, it is better.

I'm a surgeon, I love operating. But basically, surgery almost always only has benefits. So I even tell the heads of clinics, the younger surgeons, that my patients have to want to have the operation. They have to jump on the operating table and want to have the operation, so they have to be really embarrassed. You shouldn't have the operation if you're even a little bit embarrassed. And that, precisely, allows everyone to be happy. I'm happy because I did my patient a favor, who thanks me post-operatively. And the patients are happy because they get a real benefit from it. These are surgeries that shouldn't be done preventively at all. That's why we have to try to do prevention beforehand.

A: To avoid surgery, you have to take control of the problem before it gets to a complicated stage. Can't it resolve itself?

S: No

A: If we do nothing, it gets worse.

S: So for stress urinary incontinence, it's of course physiotherapy that can be maintained afterwards with endovaginal catheters. I don't really believe in endovaginal catheters, but they're a piece of equipment, like dumbbells. Like when you go to the gym, so you think about it. There are lots of different models and shapes too, because before, we had big catheters shaped like a shell. But in fact, we don't have a vagina shape at all, like a shell, made of super rigid plastic. Now, there are other silicone catheters that are much, much more ergonomic in terms of the vagina and which are, in my opinion, much more interesting.

A: Then there's the sex, too. I guess that plays a role.

S: So you can definitely contract your perineum during sexual intercourse if you want to rehabilitate it. But then you have to have enough intercourse during the week to do your rehabilitation.

A: I'll stop there. Stress urinary incontinence, you said physiotherapy and stimulating your perineum as much as possible. And overactive bladder incontinence?

S: Here, it's the patient in the perimenopause period, which, in my opinion, is a somewhat key period. There are plenty of new treatments that are mostly performed by gynecologists, which are very good: endovaginal lasers, stem cell injections. There are excellent gynecologists who do this very well, and I think it's also being taken into account. Moreover, there's even a syndrome that has emerged, so among gynecologists, not among urologists: postmenopausal syndrome, which has become a real clinical entity, for the moment a bit of a catch-all. But probably in the years to come, the definition will be a little more narrowed down.

A: What is postmenopausal syndrome?

S: It's precisely urinary problems, hot flashes, dryness, pain. It's mostly gynecologists who deal with that, me, much less. I really only deal with urinary problems, overactive bladder syndrome, which generally occurs at that point. But then, to combat these bladder problems, you actually have to quickly administer intravaginal hormones or in patients for whom there are contraindications to intravaginal hormones, particularly patients who have endometrial cancer or breast cancer. You still have to be a little careful with that. So, it can also be hyaluronic acid creams, things like that. But in any case, as soon as dryness starts, you shouldn't hesitate to apply it. And what's more, it reduces pain during intercourse. Just because you're 50-55 and you're in perimenopause doesn't mean your sex life is over. Now, with the aging of the population, you're in good shape when you're 55, you're still pretty, you're still dynamic. You still want to have sex and enjoy it. So, it's not inevitable. You have to fight against it.

A: Overactive bladder prevention is actually about hydrating the vaginal mucosa.

S: Exactly, and it's also probiotics. Take a short course of probiotics. There are plenty of probiotics available in pharmacies. I don't have any shares in probiotics, so you'll have to check that with your pharmacist. But taking a course of probiotics once every six months is good. It restores the bladder, vaginal, and intestinal flora. And there are now scientific studies coming out that are very interesting on recurring urinary tract infections. I also have a real problem with women in the perimenopause period, and in fact, they noticed by examining the microbiota of these women, there was a change in the intravesical microbiota during this period of life. So we have to fight against this again and take a little probiotics while, of course, respecting the usual hygiene and dietary rules for recurring urinary tract infections, that is to say, you have to take your time to urinate, empty your bladder well, go urinate every four hours, and not go all day without urinating. And so, that's why we say that you have to drink 1.5 liters of water per day. Because if you have two coffees in the morning and a glass of water in the evening, you're obviously not going to urinate all day, and then you can encourage urinary tract infections.

A: Okay. Have we covered the issue of prevention methods for the pathologies you are going to treat surgically?

S: Yes, I think we've covered it all. We haven't talked too much about prolapse, but prolapse (organ descent), which can affect one of the three levels of the perineum, 2 or 3:

– either the bladder, this is called cystocele or bladder prolapse. Basically, it is the tilting of the bladder into the anterior face of the vagina,

– or a prolapse that can affect the cervix and uterus. This is a hysterocele, the uterus protruding straight out of the vagina

– either the rectocele, it is the tilting of the rectum into the posterior face of the vagina which creates a ball. So, basically, our job, once the prolapse is out and bothersome for the patient, will be to see which level is affected by this descent and to propose a treatment which can be either a surgical treatment by what we call “high route”, that is to say by abdominal route or a treatment by vaginal route, or by natural routes, knowing that currently, it is forbidden to put prostheses by vaginal route. So, it will be a treatment by autologous tissue, therefore in general, which holds a little less well over time, or finally a treatment which is not surgical and it is important to talk about it here too. This is what we call the pessary. It is a rubber ring which is placed at the level of the vagina. It can be a ring or a cube, there are different shapes. It allows the prolapse to be raised and does not require surgery.

A: And it's a ring that you put on once and the patient keeps it?

S: So she can keep it for up to 3 months. But it has to be changed every three months.

A: And it's a doctor who changes the pessary?

S: Those called ring pessaries are more often used by a doctor. Then there is another type of pessary that is cube-shaped and that has to be removed every night. And that is more often done by the patient if she can manage it. But the problem is that this is generally aimed at elderly people, in any case too old to have surgery and who are not necessarily dexterous enough, skilled enough to put it on and take it off on their own.

A: This ring is used in case of inability to operate?

S: In case of impossibility of surgery, of course, or in case of a patient who does not want to have surgery.

A: Very good transition. If we've addressed all the issues of disease prevention, we'll address the question of surgery. So the moment you intervene, once all these solutions have been used or not. From the moment the surgeon enters the scene, there isn't just one way to operate. Are these trade-offs going to be made?

S: It's a matter of choice. No, there's no obligation to operate in a specific way. Currently, for all interventions concerning incontinence or pelvic floor statics, prolapses, we have the obligation to create what we call a multidisciplinary consultation meeting with urologists, gynecologists, often rehabilitation doctors, people who do what we call urodynamic assessments. Before operating, we may have to place sensors in the bladder to measure pressures, intravesical pressures, sphincter pressures. Gastroenterologists too, who deal with the procto-intestinal side and the rectocele and constipation side, or in any case, the clinical signs that can go with rectoceles. And so, we discuss patients, files to establish the best management strategy, based first of all on the patient's expectations. And that's the key word again. What does she want?

I'll give you an example. I have an 85-year-old patient, so a little old, with a bit of a history, very cute, perky, active, with urinary leaks. There was no simple solution to offer her. We couldn't use strips. She had bacterial insufficiency, so stress urinary incontinence. But since she was very old, her vagina was very fixed. She was too old to undergo an operation called the placement of an artificial urinary sphincter, which is a major procedure, but very effective, but with a complication rate of around 15 to 20%. This is a patient who wore three large diapers a day, so she had severe incontinence. So, I suggested an injection of macroplastique, a substance that is injected into the sphincter. The idea is to strengthen her sphincter. We know that with this type of technique, we're not completely effective, but we still went from three large diapers to one a day. So she said to me: "I can go back to the theater, I can go to the movies, I can take my grandchildren for ice cream," and in fact, that's what she wanted. And you have to adapt to the patient's request.

I also have a young patient who has a job where she's constantly on her feet and moving around. She also has stress urinary incontinence. The sling won't be enough for her, and she already has a sling with complications. So, we won't be able to put one on her. And I think that this patient will be offered an artificial sphincter instead.

A: So a very heavy operation, but one that she could withstand.

S: And she'll be dry with this procedure. So, actually, it depends on the situation. The practitioner must adapt to the patient's situation and expectations. A patient with a prolapse, so organ prolapse, but who isn't bothered by her organ prolapse, I wouldn't operate on her. If it doesn't bother her, we don't do anything.

A: I didn't know it was possible not to be embarrassed.

S: It depends on the degree. Of course, if it comes out a lot, it's bothersome. But if it comes out a little, you have to be wary of overestimating prolapses using imaging tests. And conversely, a patient who doesn't have a very externalized prolapse... What you need to know is that the clinical examination of prolapses changes during the day and depending on what we're doing, so you won't necessarily have the same clinical examination if you examine a prolapse at 8 a.m. as you would a prolapse at 6 p.m. after a day of running around, shopping, and picking up the kids from school. And so, a patient I owe to: "It's not coming out much, maybe we'll wait a little before operating on you." And she says to me: "Yes, but I'm really bothered. I have trouble urinating. And then, in the evening, when I take a shower, I have a lump coming out." Well, I would tend to believe her and suggest surgery, even though on clinical examination, it didn't alarm me, I didn't think it was a huge prolapse.

A: So the patient's word and the pact you make with her is at the heart of your practice?

S: Exactly, it's essential, it's what will define everything. That's why these consultations are a bit long. That's why I'm late.

A: So, I have one last question Sophie, it's in urology, we understand it well: there are a thousand ways to practice urology with different specialties.

S: That's what's good. In fact, it's a medical-surgical specialty. It's rare. In fact, we do all our complementary examinations, so that's interesting. All the bladder fibroscopies, the small cameras like in the bladder. We prescribe and do our complementary examinations. So, we manage "the chain from A to Z." It's a bit of a craft job, it's very interesting. There's also a whole medical part to our work:

The ratio of consultations to patients we operate on is ultimately quite low. We don't operate on many patients compared to the number of patients we see in consultations. It's a true medical-surgical specialty, just like URL, for example.

HAS: And you, among all the aspects of urology, you have chosen to specialize in problems that are on the border with gynecology.

S: Exactly. Well, there are several reasons. Even when I was a student, I wanted to be a gynecologist. I had a six-month internship in gynecology. I really liked it. I already have a slight tropism for women's pathologies. But I liked surgery. I wanted to be a surgeon, and in fact, in the gynecology residency, there are quite a few semesters in obstetrics where we deliver babies. And it wasn't something I liked at all. It was something that even worried me. So I didn't choose gynecology and what's more, at the time, I was told: "If you want to do surgery, it's better to do a surgical residency because then you spend 5 years doing nothing but surgery to get optimal training, which is why I chose urology. And then, in urology, I specialized in pelvic statics quite early on because I did my medical thesis, for example on botulinum toxin in the bladder. So the same thing as for wrinkles, but that we can do directly in the bladder to treat overactive bladder, precisely. But that's more of a meeting, because at the time, when I became an intern, there were very few female urologists. We're still 3% women. It's really a specialty, ultimately, still male, even if it's really changing. But basically, we said that urology is a bit like a man's gynecologist. No, actually, he's really a practitioner for women, and at the time, I was in a department where there was a woman who was a Ph (hospital practitioner) called Sophie and who had three children. At the time, I was thinking that it was going to be complicated to have a family life, to do surgery because these are demanding jobs and you spend your nights and days there. You know when you start and you don't know when you finish. And so I saw her, who had her three children. It wasn't easy, she was struggling, but in the end, like we all struggle. So, I said to myself: "it's possible." I identified with her a bit. And then, it's like everything: when you're interested in a field. So, it continues to be interesting and so on. And there you go.

HAS: And so, from gynecology, you finally chose another specialty, but still in women's health.

S: Exactly. I find it's not easy to be a woman in 2021. So there may be men who will listen to us, who will have their hair standing on end, but I find that we do a lot of things. We work, we take care of our children. In any case, we worry about them. We also have to be considerate of everyone. Well, I already find that not easy. So, if I can make women's lives a little easier and help them get back to normal life... What makes me happiest is when people come to see me afterwards and say: "Doctor, you changed my life." And that's a phrase I hear quite regularly. And that's why I do this job. And it has to continue. Thank you very much.