How to overcome taboos surrounding the pelvic area?

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 of the Georges Pompidou European Hospital. I am also a member of the Curopf, the Committee for Urology and Female Pelvi-perineology, which is referenced by the French Association of Urologists, and I deal more specifically with what is called pelvic statics, meaning urinary incontinence and prolapse (pelvic organ descent). So, it’s a bit of a sub-specialty of mine in the department, even though I also do a bit of oncology, of course.

A: In the context of 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 it’s partly because women, ultimately, when they have this type of pathology, prefer to see a woman because they feel that they are better understood, not judged. In any case, it causes them less anxiety. And then, it touches on intimacy, on the clinical, gynecological examination, so it’s true that I have the impression that women prefer to see women. Not necessarily for a good reason, of course, because a man is perfectly capable of practicing this specialty. From the moment we are doctors and we wear a white coat, we are neither a man nor a woman.

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

S: Exactly, that’s why I accepted to do this podcast because we have to fight against the taboo. And I still feel currently, even if things are really starting to change because women’s magazines are starting to talk about it, we see ads on TV for adult diapers, so it’s becoming a little less taboo, but ultimately when it affects you personally, it remains a bit shameful. Because perhaps there is a fear of smelling like urine. It still remains something that causes women pain and shame, actually. And that’s why we absolutely must talk about it because there are solutions. There are solutions that are adapted to each patient, solutions that aren’t necessarily surgical or, in any case, not necessarily surgical right from the start. So, that’s why we also need to come see us quite quickly before having catastrophic leaks. Because there, it’s true that as a result, the solutions are inevitably a bit more surgical. In any case, it’s not because you go to see a surgeon that you are going to get operated on. So I think we really need to come for a consultation quickly, talk to a general practitioner about it, and fight against taboos because there is no shame. Everyone has the right to have the pelvic life that suits them and that they want.

A: That’s great because you delivered the message that was close to your heart right away! We know each other a little in informal life and you were very keen to be interviewed because you told me “I want everyone to know”.

S: Exactly, actually, it’s a specialty that is very interesting compared to oncology. Oncology is very interesting, but ultimately, when you treat cancer, there is what we call guidelines, which are recommendations; basically, we know more or less what we have to do: for every situation there is a given solution that, in an identical situation, is the same for everyone. Pelvic statics is, in my opinion, much more interesting because it is the situation that adapts to the patient; there is a personalized solution for each patient.

A: What you’re saying is extremely interesting and then I know you’re going to address the question of quality of life, the compromises to be made to adapt quality of life to the patient’s clinical situation. And before that, I would like to go back to the beginning: urinary incontinence and prolapse, meaning pelvic organ descent. What are they? Which populations are affected by this type of pathology?

S: So, the prevalence is enormous. The prevalence is the incidence rate; it’s the number of people affected in the population. It’s huge. Stress urinary incontinence is urinary incontinence when coughing, doing sports, jogging, or trampolining. To give you an example, urinary incontinence on a trampoline affects 80% of women. I, who have had children, if I go on a trampoline, I could probably have a small 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 the urinary incontinence of the young woman, affecting about 15% of the female population. It’s huge.

A: These women could seek advice because the disorder is sufficiently established and bothersome.

S: Actually, they should seek advice when it becomes bothersome.

A: Okay, before that we don’t come, because we don’t jump on a trampoline every 4 mornings?

S: Absolutely, if you don’t jump on a trampoline every morning and it’s not bothersome, you don’t need to consult. So, in fact, what you really need to do is consult when you are bothered. On the other hand, what must be clearly explained 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 are on 4 legs don’t have prolapse; we have prolapse because we are upright, because we walk on 2 legs.

The perineum is a muscle, therefore, when you start to have very small leaks, you must do rehabilitation to strengthen the perineum. This will, of course, avoid prolapse and you will gain continence. And this rehabilitation must be done by all patients.

A: For those who have had children, it’s quite easy to imagine leaks because they had perineal rehabilitation, so they see more or less what it is and they might be able to do the movements again on their own.

S: Exactly, that’s it, there are also an enormous number of patients who do their rehabilitation and particularly their postpartum rehabilitation and who, afterwards, do nothing more. But it’s exactly the same principle as the gym: if you exercise two months before summer to get rid of your belly, to tone up, remove cellulite, you’ll look good in a swimsuit. But if in September you stop everything, it will come back. In urinary incontinence, it’s the same thing. When you have done your 15 to 20 physiotherapy sessions, you have to continue doing the exercises at home, otherwise it will come back! It’s maintenance, just like we maintain our abs, we must also maintain our perineum because your perineum is what supports us when we walk.

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

S: And in fact, you shouldn’t make a mistake because there are two main types of incontinence. There is the stress urinary incontinence that we just talked about and the urinary incontinence due to an overactive bladder. That is a urinary incontinence that generally appears much later in life, in the absence of neurological disorders. It’s the urinary incontinence of the menopausal woman, with a prevalence that also increases with age, because the older we get, the more we have it. But it affects about 25% of women from the age of 65, so it’s huge too.

A: And do we know what it’s caused by?

S: It’s really multifactorial. In fact, the first cause we can fight is the trophic disorders of menopause. Actually, at menopause, the hydration of the vaginal mucous membranes changes, so there is vaginal dryness that then creates changes in the vaginal microbiota, but also the bladder and intestinal ones. All these small modifications can lead to overactive bladder.

What is overactive bladder syndrome? It’s what we call urgency, it’s 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 decrease in the safety delay. Pollakiuria, meaning the fact of going to urinate often during the day, with more or less leaks, because we see that there are patients who have leaks in the syndrome and others who do not.

A: You gave me an example that was very telling: there are women who, since the cafes closed, can no longer leave their homes because they cannot imagine having to go to the bathroom when they need to.

S: Exactly, I have many patients who had a real problem when cafes closed due to COVID. Because they organized their walks according to the toilets they knew. As a result, life is organized around toilets. They weren’t going out anymore because they were saying to themselves: “If I ever need 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, it can be a complete urination. So, in fact, you are soaked. The symptoms of these two types of incontinence are really different. And the treatments we can propose are diametrically opposed.

A: And I imagine, what’s more, that as is often the case in medicine, it’s never all 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 other symptoms, we speak of pure stress urinary incontinence. For overactive bladder syndrome, I already explained it to you. But there are unfortunately an enormous number of women who have a little bit of both. And so there, that’s the grey area, that’s the difficulty. I, like quite a few urologists, try to conduct a police interrogation, because it’s a real investigation. It’s a consultation that must, therefore, last a long time because you have to determine in your patient which type of incontinence bothers her the most. And I tend to treat that type of incontinence first and then see what is left.

A: So there, we are going to return to a subject you touched upon at the beginning, it 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 is a kind of bashing regarding prostheses and prostheses that treat stress urinary incontinence. We all saw the "Envoyé Spécial" report on the subject with prostheses that are currently banned in England, in Anglo-Saxon countries. So, there is a real fear regarding that. And so, anyway, every patient before surgery must have physiotherapy. It’s medico-legal. Okay, so, physical therapists are not finished having work.

A: So there is a first phase.

S: Yes, it’s 15 to 20 sessions. It’s the physical therapist who decides the number of sessions. If at the end of these sessions, the physical therapist says: “I am at the maximum of what I have been able to recover, in terms of contraction”. And there, two solutions. We adapt again to the patient, either she says “I’m really fine, I’m doing much better since I did the physiotherapy, I’ve really become aware of my perineum”, because there’s also that. Some patients don’t know what the perineum is.

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

S: The perineum is your keystone. It includes the bladder, the vagina, thus 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 is called a perineal test, a vaginal touch. And I ask them to contract against my finger, I have patients who push. That’s called a reversal of command. And even you there, if I ask you, “come on, contract your perineum there”.

A: Well 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 in the subway, I do it.

S: Thanks to that, you will never need me. That’s why you really have to do preventive work on the perineum and I think it’s not said enough. And I also have the impression that there are quite a few obstetrician-gynecologists who, once they have finished their work, ultimately don’t insist. It’s not work that we do three days postpartum, it’s more 6 months to a year after childbirth.

A: Do the risks associated with the perineum begin from the moment you have given birth?

S: Childbirth and obstetric trauma, meaning either births that were difficult with forceps, episiotomy where we are forced to cut the perineum a little, or very explosive births, where the patient gave birth very, very quickly, and as a result, the child came out like a bomb. These births, inevitably, cause damage.

A: But a woman who has not had children, unless she is a high-level athlete...

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

I would like to come back to obesity because there are factors we can influence and others we cannot. Obesity, which is worsening in the general population, is a true aggravating factor for stress urinary incontinence. And we must still tell patients that if they reduce their weight by 10%, they can reduce leakage by 50%. So, for obese patients (with a BMI – body mass index – greater than 35), we really must try to help them lose weight before operating because their incontinence will improve. It will improve all other cardiovascular and joint factors as well. Furthermore, we know that obesity is a risk factor for surgical complications and treatment failure. Therefore, we must try to help them lose weight before offering them surgical management.

A: So, if I go back a bit to what has been said, basically, you insist a lot on prevention, meaning not waiting to consult once the disorders are confirmed, established, and have been present for a long time.

S: I insist on the fact that if the disorders are confirmed, you must above all go see your doctor, but if it is possible sooner, it is better.

I am a surgeon; I love to operate. But generally speaking, surgery almost never has only benefits. So I even tell the clinic heads, the younger surgeons, that my patients need to want to have surgery. They need to be jumping on the operating table and wanting to be operated on, meaning they must be truly bothered. You shouldn't have surgery if you are only a little bit bothered. And that, precisely, allows everyone to be happy. I am happy because, consequently, I have been of service to my patient, who thanks me post-operatively. And the patients are happy because they gain a real benefit from it. These are surgeries that should not be done preventively at all. That is why we must try to do prevention first.

A: To avoid surgery, one must take the problem in hand before reaching a complicated stage. It cannot resolve on its own?

S: No

A: If we do nothing, it gets worse.

S: So for stress urinary incontinence, it is, of course, physical therapy, which can be maintained afterward using endovaginal probes. I don't believe much in endovaginal probes, but it is equipment, like dumbbells. Like when you go to the gym, so you think about it. There are many different models and shapes too, because before, we had large, shaped probes, like a shell. But in fact, we don't have a vagina shape like a shell made of super-rigid plastic at all. Now, there are other silicone probes that are much, much more ergonomic in terms of the vagina and which are, in my opinion, much more interesting.

A: Then, there is also sexual intercourse. I imagine that plays a role.

S: Well, one can absolutely contract their perineum during sexual intercourse if they want to do their rehabilitation. But then, you have to have a sufficient number of acts in the week to do your rehabilitation.

A: I will stop there on that question. Stress urinary incontinence, you said physical therapy and stimulating the perineum as much as possible. And overactive bladder incontinence?

S: There, it is the patient in the perimenopausal period, which, in my opinion, is a somewhat key period. There are many new treatments that are rather done by gynecologists that are very good: endovaginal lasers, stem cell injections. There are excellent gynecologists who do that very well, and I think that it is also starting to be taken into account. Moreover, there is even a syndrome that has emerged among gynecologists, not among urologists: menopausal woman 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 bit more tightened.

A: What is menopausal woman syndrome?

S: It is precisely urinary disorders, hot flashes, dryness, pain. It is rather the gynecologists who take care of that; me, much less. I really only take care of urinary disorders, of the overactive bladder syndrome which, in general, arrives at that moment. But, to fight against these bladder problems, in fact, one must quickly introduce intravaginal hormones or, in patients for whom there are contraindications to intravaginal hormones, notably patients who have endometrial cancer or breast cancer. One must still be a bit careful with that. So it can also be hyaluronic acid creams, things like that. But in any case, as soon as you have dryness starting, you must not hesitate to apply them. And besides, that decreases pain during intercourse. It is not because one is 50–55 and is in the perimenopausal period that sex life is over; now, with the aging of the population, we are in good shape when we are 55, we are still pretty, we are still dynamic. We still want, precisely, to have intercourse and enjoy it. So it is not an inevitability. One must fight against inevitability.

A: Overactive bladder, prevention is actually hydration of the vaginal mucosa.

S: Exactly, and it is also probiotics. Do a small course of probiotics. There are many probiotics for sale in pharmacies. I don't have shares in probiotics, so you must see that with your pharmacist. But doing a course of probiotics once every six months is good. It restores the bladder, vaginal, and intestinal flora. And there are now scientific studies being published that are very interesting regarding recurrent urinary tract infections. I have a real problem there too with women in the perimenopausal period, and in fact, they realized by examining the microbiota of these women that there was a modification of the intra-bladder microbiota during this period of life. So one must fight against that, once again, and take some probiotics while, of course, respecting the usual hygienic-dietary rules for recurrent urinary tract infections—that is to say, you must take your time to urinate, empty your bladder well, go urinate every four hours, and not stay all day without urinating. And that is why we say you should drink 1.5 liters of water a day. Because if you drink two coffees in the morning and a glass of water in the evening, naturally, you won't urinate during the day, and there, you can promote urinary tract infections.

A: All right. On the question of prevention methods for the pathologies that you treat surgically, have we covered everything?

S: Yes, I think we have covered it. We didn't talk much about prolapse, but prolapse (organ descent), which can involve one of the three levels of the perineum, 2 or 3:

– either the bladder, that is called a cystocele or bladder prolapse. Basically, it is the sagging of the bladder into the anterior wall of the vagina,

– or a prolapse that can involve the cervix and the uterus. That is the hysterocele, the uterus that comes straight out at the level of the vagina

– or the rectocele, which is the sagging of the rectum into the posterior wall of the vagina that creates a bulge. So, basically, our job, once the prolapse has protruded and is bothersome for the patient, will be to see which level is concerned by this descent and to propose a treatment that can be either surgical treatment via what is called the “high route,” meaning abdominally, or treatment via the vaginal route, meaning via the natural pathways, knowing that currently, it is forbidden to put mesh via the vaginal route. So, it will be treatment using autologous tissues, meaning generally it holds a little less well over time, or finally, a treatment that is not surgical, and it is important to talk about it here too. It is what is called a pessary. It is a rubber ring that 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 lifted and avoids surgery.

A: And it is a ring that you put in once and the patient keeps it?

S: Well, she can keep it for up to 3 months. But it must be changed every three months.

A: And it is a doctor who changes the pessary?

S: For what we call ring pessaries, it is rather a doctor. Then, there is another type of pessary that is cube-shaped, and there, it must be removed every night. And there, it is rather the patient who does it if she can. But the problem is that, consequently, this is addressed to elderly people in general, in any case too old to have surgery and who are not necessarily dexterous or skillful enough to put it in and take it out all by themselves.

A: Is this ring used in case an operation is impossible?

S: In case an operation is impossible, for sure, or in the case of a patient who does not want to have surgery.

A: Very good transition. If we have finished all the issues regarding prevention of pathologies, we are going to bring up 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 is not only one way to operate. Are there trade-offs that will be made?

S: They are trade-offs. No, there is no obligation to operate in a precise way. Currently, for all procedures concerning incontinence or pelvic floor stability, prolapses, we have an obligation to create what is called a RCP (multidisciplinary consultation meeting) with urologists, gynecologists, often rehabilitation physicians, people who do what are called urodynamic assessments. Before operating, we may have to insert sensors into the bladder to measure pressures, intra-bladder pressures, sphincter pressures. Also gastroenterologists, who take care of the proctology side and the rectocele and constipation side, or in any case, clinical signs that can go with rectoceles. And so, we discuss the patients, the files, to establish the best management strategy, first and foremost based on the patient's expectations. And that, once again, is the keyword. What does she want?

I will give you an example. I have an 85-year-old patient, so a little elderly, a few medical histories, very sweet, chic, active, with urinary leakage. There was no simple solution to offer her. We could not put in bands. She had bacterial insufficiency, so stress urinary incontinence. But since she was very old, her vagina was very fixed. She was too old to perform a procedure called the placement of an artificial urinary sphincter, which is a heavy procedure, but very effective but with a complication rate of about 15 to 20%. This is a patient who was wearing three large pads a day, so, severe incontinence. And so, I proposed an injection of macroplastic, a substance that is injected into the sphincter. The idea is to strengthen her sphincter. We know that with this type of technique, we are not completely effective, but we still went from three large pads to one per day. So she tells me: “I can go back to the theater, I can go to the movies, I can take my grandchildren to eat ice cream,” and actually, that is what she wanted. And one must adapt to the patient's demand.

I also have a patient who is young, who does a job where she is always standing and moving. She also has stress urinary incontinence. The band will not be enough for her and she already has a band with complications. So we won't be able to put one in for her. And I think that for this patient, we will rather propose an artificial sphincter.

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

S: And she will be dry with this procedure. So, in fact, it depends on the situation. The practitioner must adapt to the situation and to the patient's expectations. A patient with a prolapse, meaning an organ descent, but who is not bothered by her organ descent, I will not operate on her. If it does not bother her, we do nothing.

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

S: It depends on the degree. It is certain that if it protrudes enormously, it bothers. But if it protrudes a little bit, one must be wary of over-evaluating prolapses through imaging exams. And conversely, a patient who does not have a very exteriorized prolapse... What you need to know is that the clinical exam of prolapses changes during the day and depending on what we do, so you won't necessarily have the same clinical exam if you examine a prolapse at 8:00 AM as a prolapse at 6:00 PM after a day of running everywhere, having gone to do the shopping and having gone to pick up the children from school. And so, a patient to whom I say: “It doesn't protrude too much, we will maybe wait a little before operating on you.” And she tells me: “Yes, but I am super bothered. I have trouble urinating. And then, in the evening, when I take my shower, I have a lump that comes out.” Well, I would tend to believe her and offer her surgery, whereas, upon clinical examination, it did not alarm me; I did not think it was a huge prolapse.

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

S: Exactly, it is primordial, that is what will define everything. That is why these are somewhat long consultations. That is why I am late.

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

S: That is what is good. Actually, it is that it is a medical-surgical specialty. That is rare. In fact, we do all our complementary exams, so that is interesting. All the bladder fibroscopies, the small cameras like in the bladder. We prescribe and perform our complementary exams. So, we manage “the chain from A to Z.” It is a bit of craftsmanship, it is very interesting. There is also an entire medical part of our work:

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

A: And you, among all the areas of urology, you have chosen to specialize in issues that are at the border with gynecology.

S: Exactly. So, there are several reasons. Already, 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 small tropism for women's pathologies. But I liked surgery. I wanted to be a surgeon and in fact, in the gynecology internship, there are quite a few semesters in obstetrics where, consequently, one performs deliveries. And that was not a thing that I liked at all. It was even something that worried me. So I didn't choose gynecology and besides, at the time, they told me: “If you want to do surgery, it is better to do a surgery internship because, consequently, one spends 5 years doing only surgery to have optimal training,” which is the reason why I chose urology. And then, in urology, I specialized in pelvic stability, finally quite early, because I did my medical thesis, for example, on botulinum toxin in the bladder. So the same thing as for wrinkles, but that one can do directly in the bladder to treat overactive bladder, precisely. But that, it is rather encounters, because at the time, when I became an intern, there were very few female urologists. We are still only 3% women. It is really a specialty, ultimately, still masculine, even if it is really starting to change. But basically, they used to say that the urologist is a bit the gynecologist for men. No, in fact, it is 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) whose name was Sophie and who had three children. At the time, I told myself that it was going to be complicated to have a family life, to do surgery because these are jobs that are demanding and we spend our nights, our days there. We know when we start and we don't know when we finish. And so I saw her, who had her three children. It wasn't a walk in the park, she was struggling, but finally, as we all struggle. Consequently, I said to myself: “It is possible.” I identified with her a bit. And afterward, it is like everything: when one is interested in a field. Consequently, it continues to be interesting and so on. And that is it.

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

S: Exactly. I find that it is not easy to be a woman in 2021. So there may be men who will listen to us who will have their hair stand 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 must also be attentive to everyone. There, I find that already not easy. So, if I can make life a little easier for women and they can resume a normal life... What gives me the most pleasure is when people come to see me afterward and tell me: “Doctor, you changed my life.” And it is a sentence that I am told quite regularly. And that is why I do this job. And it must continue. Thank you very much.