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I'm about to tell you a very important secret. It will shock you and disturb you. It will make you angry, and possibly miserable. But it will also make you free. Free from unreasonable expectations. Free from unneccessary but inevitable disappointment. Free from chasing after unattainable perfection and free from blaming others, including your surgeon.

You see - for too long physicians, gynecologists and pelvic floor surgeons have misled their patients into thinking they can do, and accomplish, that which they cannot.

I've been working in the field of pelvic reconstructive surgery for twenty five years and know a thing or two. I've seen things coming; I've seen things going. My patients and I have walked the same walk hundreds; no - thousands of times. I've been there; done that and smelled the roses or reaped the results, with my patients. I've experienced their expectations, their happiness at met expectations, but also their disappointments and their anger - sometimes directed straight at me.

I've learnt a few things through the years and I plan to share some of them here soon.

The simple truth is that we can do much less than most people suspect. In fact, we cannot solve, nor really successfully cure, most pelvic floor disorders. That is of course true in many medical fields, but even more so in pelvic reconstructive surgery.

Most patients coming to our clinic, or who see me at my practice, believe that they can be made whole again. That the pelvic floor injuries sustained during childbirth, or during a lifetime of straining, or as a result of previous surgery, can be undone - cured if you will. Well, unfortunately the dirty little secret, is we can do no such thing. We cannot 'fix', cure, or make whole, nerve injuries, torn fascia, stretched, torn or abscent pelvic floor muscles, or any of a large number of associated problems all combining to bring our patients through the door in the first place. We cannot usually cure, or fix the many functional disorders leading to many symptoms, especially many chronic pain conditions, bowel related issues or some bladder conditions.

What we urogynecologists can attempt to do, if we decide on surgery, is to TRY and compensate for the damage. To do so in a scientifically honest way however, requires a very deep understanding of the pelvic floor, the damage sustained as mentioned above, and its various disorders and dysfunctions. This does not come overnight. This is not gained during residency and definitely not during medical school.
The problem is that the medical profession has been a victim of its own successes. Many, if not most patients believe that we can cure almost anything, and when there's a bulge, that surgery will fix it, if it's only done correctly. The obvious corollary is that if it's not fixed, the surgery must have been done incorreclty, or poorly.

I know of course, and admit, that I'm generalizing. Many patients understand what I'm trying to say here, but I'm trying to get a point across. To get your interest I needed to be dramatic, and it must have worked since you're reading this.

The fact however is that one of our responsibiities as pelvic reconstructive surgeons is to make absolutely sure that patients understand the limitations of our surgical offerings, the very high surgical risks (whether or not mesh is used - a whole other topic), and the extremely high failure rates of pelvic floor reconstructive surgery. In no other surgical field will such high failure rates be tolerated, mostly because these rates don't exist anywhere else, which is one of our problems and another cause for high expectations, which we can't meet. I strongly believe that pelvic floor reconstructive surgery is one of the most difficult surgical specialties precisely because of this elephant in the room. We are continually trying to bring down expectations, manage disappointment and create an atmosphere of learning how to live with a chronic, incurable condition, which a very large percentage of the female population develop.

When signing up for pelvic floor reconstructive surgery, it should NEVER be promoted as a final cure. It is more likely to be a temporary amelioration. Possibly the first operation towards a repeated cycle of improvement, worsening and further assessments. Of course we 'hope' to 'fix' the problem with our surgery once and for all. But how does surgery prevent elastic tissue from stretching again? Gravity to stop pulling? Weak and torn (or even abscent) pelvic floor muscles to improve their support function? Scar tissue to stop weakening with aging?  Of course surgery does none of these things, and therefore it is not a final 'event' in the pelvic floor journey. It is one of many options along this road.

Surgery should never be considered lightly. It should almost never be the first or only treatment. I'm not going into more conservative treatments in this essay, but I've written about it extensively elsewhere.It should be done by someone who has experience, special training and the resources to offer associated, extremely important advice and allied health treatments for instance physiotherapy. I will go as far as to state that undergoing pelvic reconstructive surgery without a pelvic floor physiotherapy assessment, if not before, then certainly after the surgery, is insane. Would you expect a shoulder reconstruction without physiotherapy? Of course not. But for some reason in pelvic floor reconstruction many people want things to be done 'for' them, with no effort on their part. The end results often then speak for itself.

The fact is that if someone has a bad prolapse, or incontinence (this essay is mostly about prolapse) - there are usually more than one cause. The reasons and origen of the prolapse are often a complicated interplay of muscle, fascia, nerve, bony pelvic and associated structures. Body mass index, lifestyle, genetics (strength of an individual's connective tissue), all play a very large role as well. Surgery is one option, but needs to be in context of what it can do, what is unlikely and what it will definitely not do. Most non urogynecologists have a very poor understanding of this.

Successful surgical outcomes in prolapse surgery is internationally defined as where any remaining bulge does not come THROUGH the vagina, and is not symptomatic. Note that I did not say 'there is no bulge remaining'. The remaining bulge does not come 'through' the vaginal opening! I want to write that again.... remaining bulging is of such a degree that it does not bulge further (through) than the vaginal opening (in our specialty that is defined as Stage II prolapse). 

What does this say about patients who request, or sometimes demand surgery for a bulge that is still inside the vagina? PRECICELY! This is half of our problem right there - the expectations are not in line with reality. Most women who had vaginal childbirth has some degree of vaginal laxity. Not all, but many. Stage 0 prolapse does not exist. It's an utterly rediculous thing to tell a women with minor descent of the vaginal walls that she has prolapse. Everyone has prolapse then - or most vaginally parous women anyway. Stage I 'prolapse' is NORMAL. Stage II prolapse doesn't mean you need or should even have surgery, or have surgery again. (There are always exceptions and some women become symptomatic earlier than others). But as a general rule offering surgery, or giving in to such requests is not in anyone's interest. The patient is set up for failure since she might not notice much improvement and has to take all the risks of the surgery - for what? It's also not in the interest of the surgeon, since she or he is also set up for failure. When the patient comes back with the same bulge afterwards - then what? Everyone's unhappy and trust is lost. Since it was considered that the problem required the extreme of surgery in the first place  and it's still the same - are you now going to be able to convince that same patient that she should forget it and ignore it? A bit naive.

I decided to write this follow up to my teaser even though I don't think the topic is exhausted. I'll probably continue to come back to it to expand it, edit it and hopefully improve it. However I wanted to get thus off my chest, so decided to throw the words proverbially at the screen for now as an initial trial to say what I hope makes some sense. Half of the stress of my profession is this interplay between real distress and severly life altering conditions for some, minor inconvenience for others with lesser issues, and the expectations - often set up by well meaning but poorly informed primary caregivers or even specialists who are not dealing with this day in and day out. I just returned from vacation and after two days in clinic I'm already feeling the stress of trying to manage the high expectations patients bring, and the high expectations that we physicians put on ourselves to do right by our patients. Sometimes that means telling our patients we can't 'cure' their problem or refusing a demand for surgery, or explaining why the small remaining bulge in the vagina after surgery for previously severe prolapse doesn't mean their operation failed, and why we will not be doing another operation for it regardless of how much they want it to be otherwise. Real caring for our patients takes fortitude and a real love for the profession; especially to do this day in, and day out, year after year. I take my hat off to all my colleagues worldwide who succeed. We are a relatively small group after all.

 Feel free to comment on the pelvicfloorcalgary facebook page.

M Murphy