Coping with prostate cancer's emotional toll; therapy for the pelvic floor; getting a hernia repaired; Upstate Medical University's HealthLink on Air for Sunday, Feb. 20, 2022
Rehabilitation psychologist Dorianne Eaves, PsyD, discusses the psychological aspects of prostate cancer. Doctors of physical therapy Jillian Cardinali and Tania Gardner tell who may be helped by pelvic floor physical therapy. Surgeon Moustafa Hassan, MD, and nurse coordinator Maggie Wight explain what to expect from hernia repair.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a psychologist specializing in oncology discusses the psychological aspects of prostate cancer ...
Dorianne Eaves, PsyD: ... What fears and anxieties do they have, as well as how can we manage this stressful situation with coping strategies, relaxation ...
Host Amber Smith: ... Two physical therapists explain which patients may be helped by pelvic floor physical therapy ...
Jillian Cardinali, DPT: ... We do see patients for any form of pelvic pain, patients who are pregnant or postpartum, some postoperative patients ...
Host Amber Smith: ... And a surgeon and a nurse coordinator talk about what to expect if you or a loved one face hernia repair ...
Maggie Wight: ... Our program focuses on including self-care for healing and recovery, exercises to enhance your repair and impact your recovery ...
Host Amber Smith: ... All that, plus a visit from The Healing Muse, right after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a pair of physical therapists tell about pelvic floor physical therapy and which patients it may help. Then, a surgeon and a nurse coordinator talk about what to expect from hernia repair. But first, a psychologist discusses issues that may arise after prostate cancer.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
More men are living longer with prostate cancer, thanks to better treatments and better diagnostic aids. Many of these men face anxiety, depression or fear, in addition to physical problems. Today, I'm talking about the psychological impact of prostate cancer with Dr. Dorianne Eaves. She's a psychologist from the Psychosocial Oncology Program at the Upstate Cancer Center.
Welcome to "HealthLink on Air," Dr. Eaves.
Dorianne Eaves, PsyD: Thank you for having me.
Host Amber Smith: Do you see men right after diagnosis or during treatment?
Dorianne Eaves, PsyD: I can see men at any point along the continuum of treatment, often at initial diagnosis, throughout treatment, or even post-treatment, it's really, whenever they feel like the best support is needed. I can meet patients at any time during that time.
Host Amber Smith: Do you see men along with their partners, or is this usually individual counseling?
Dorianne Eaves, PsyD: I can do both. I can see the patients individually, or after seeing them individually, if they feel like it'd be helpful to add their spouse in or a family member, I can certainly do that as well.
Host Amber Smith: Do most men find you because of a referral from, or a suggestion from their physician?
Dorianne Eaves, PsyD: Yes. The referrals can come from any of their providers, nursing staff, really any time, so often they come through referrals that way.
Host Amber Smith: Well, let's start with anxiety and fear. How do you advise cancer patients to manage anxiety and fear?
And I imagine this applies beyond prostate cancer, but that's probably a pretty common issue, isn't it?
Dorianne Eaves, PsyD: It's very common. That is often what I am seeing people for: for the emotional distress, fear and anxiety that a cancer diagnosis produces, as well as just the treatment, treatment side effects and the difficulties that come with cancer diagnosis and living with cancer.
So I often meet people then, and I tell people all the time that it's a normal reaction to your abnormal situation of a cancer diagnosis and living with cancer. So there's a lot of different things that we can do: meeting --with the patients, different relaxation strategies, coping strategies, finding a way of living with cancer and still a quality of life and well-being that is important to them and within their values.
Host Amber Smith: With prostate cancer specifically, are there common fears that men have?
Dorianne Eaves, PsyD: Yes, I would say that it's just as you were saying earlier, the common cancer diagnosis reaction that comes from for everyone, of the mortality and longevity and what does it mean to have a cancer diagnosis?
What does this mean for my life? For my well-being, for my family, all of those things. And then specifically with prostate cancer, it's the fears and anxieties of treatment. What treatments will look like, treatment options and decisions, as well as the scans and different procedures that happen with diagnoses and treatments, what the side effects will look like and how that will impact them, their life, their families, their relationship, and then also common to cancer as a whole is fear of recurrence; even post-treatment, the regrets, having completed treatment, the decisions made. There's just a lot of things that impact well-being and emotional distress with cancer.
Host Amber Smith: It seems huge because you have these day-to-day issues, how this is going to impact their life, hour by hour, day by day, but also, life-changing, big issues, so yeah, I imagine it's a lot to struggle with. Do you ever have patients who question the cause of their cancer or whether they did something to deserve it?
Dorianne Eaves, PsyD: That is common too. And I often hear it from people who were healthy before cancer, rarely seeing a doctor, rarely being even sick with a cold or flu. and they often feel like their body has betrayed them because they did what they were supposed to. They lived healthy, they were exercising, eating well, so this can be a common reaction, and it's along that continuum of a grief process in reaction to cancer. So we just process through this and we often are hardest on ourselves, so it can be just a reframing approach of what would you tell a friend in this instance? And then also certainly looking back and reflecting on life pre-cancer and what led to a diagnosis, but also trying to reframe and bring them back into the present and what acceptance looks like now with cancer, and acceptance doesn't mean approval of the diagnosis and living with cancer. But what does it look like and how can you still live within your values and a quality of life now, even when all of these changes and life-altering situations come in that certainly don't diminish the distress and grief that comes with a cancer diagnosis.
Host Amber Smith: With prostate cancer, many men will have a multitude of treatment options to choose from, and that alone can feel overwhelming. How do you advise them to just manage the stress of figuring out what's the best course for them?
Dorianne Eaves, PsyD: It is really difficult because these decisions feel very heavy, especially when so much feels out of their control. And it's during a time where you're emotionally distressed and overwhelmed and worn down and then making these really important, heavy decisions. So I think that's often where my role comes into play the most, of meeting the patient where they're at, talking through what the treatment options even are and being that liaison and middle person between their medical team and a care team and the patient and bridging that gap and discussing, OK, well, what are the treatment options? Knowing and seeing if they have a full understanding of that and then processing through that with them and supporting them and seeing what their goals for treatment are, what it looks like for them to have a quality of life. What's important in those aspects. What's important for them in treatment and post-treatment and weighing all the options and figuring out what feels best to them and also bringing in their caregivers, their families, their spouses, and helping support them and using them during these times.
Of having a support person, hopefully being able to go to the appointments with them or being on the phone with them and writing notes and being the ones to ask the important questions that are important to the patient and the family, because it can be a lot of information thrown out at the patient and just an overwhelming time that's difficult to process and even hear everything and even remember the questions that they might have.
So working out strategies for that. And also knowing it's not a right versus wrong equation of making these decisions. It's just what is most important to them and what feels best to them in the moments with that information that they have now.
Host Amber Smith: This is Upstate's "HealthLInk on Air." I'm your host, Amber Smith, talking with psychologist Dorianne Eaves from the Upstate Cancer Center's Psychosocial Oncology Program.
Sometimes doctors recommend a period of, they call it watchful waiting, where they're tracking the PSA numbers real carefully (prostate-specific antigen is checked in prostate cancer screening and treatment). Is that inherently stress inducing for a patient?
Dorianne Eaves, PsyD: It can be. It's often similar to those times when you're in between treatment, you've completed one treatment and you're waiting for scans to reassess. That can be a very anxiety-provoking time. It's often like if I said, "Don't think about the white elephant in the room," and that's all you can think about.
So this is often a time when I see patients and working through, OK, what fears and anxieties do they have, as well as how can we manage this stressful situation with coping strategies, relaxation? What racing thoughts are coming up for you and how can we manage those?
Because it can be a very difficult time. And then when someone tells you to not be stressed, can just increase that moreso.
Host Amber Smith: How is the depression that some cancer patients experience? Is it different from regular depression?
Dorianne Eaves, PsyD: It can be different in very small, different ways. Oftentimes it might not meet criteria for clinical depression, but grief and emotional distress near depression, and look like depression in a lot of ways.
And then it's also difficult because treatment and treatment side effects can impact mood similarly to depression and anxiety, so there's a lot of different factors playing here. That's also when it's important, when I meet with patients, to have these discussions and during my initial intake, asking the questions of, OK, what symptoms are you experiencing?
How is your mood? And figuring out, is this at a clinical level where medications might be helpful. And that's always a discussion we have and referral options that are discussed to see where to go from there. As well as knowing and validating the patient. And this is a common reaction; grief and emotional distress and depressed mood and anxiety are all common with cancer diagnosis and cancer treatment.
And whether it's clinical versus not, there's still things that we can do in coping strategies and things that are very similar. It might just be medication added if it is to a clinical level that we feel might be helpful to add medications along with therapy.
Host Amber Smith: So there are some medications that can be prescribed that won't interfere with chemotherapy or other treatments?
Dorianne Eaves, PsyD: Correct. Yes, and that's always a discussion we have, whether their medical care team, their oncologists, might prescribe medications or talking with their primary care provider, or if it's to the level of psychiatry services, a referral might be helpful. We can always have those options to discuss.
Host Amber Smith: Now a lot of times, exercise is recommended as a way to help people improve their mood.
But when someone's in treatment for cancer, the fatigue can be severe.Do you have suggestions for what physical activity might be beneficial, but not too taxing?
Dorianne Eaves, PsyD: Yes, I always encourage patients to talk to their medical care team about what activities, like, what is the level of functioning and what activity level they can (achieve), so it's not too straining or, given certain treatments or surgeries or different things, what the activity level should be. And it's often really difficult because people are frustrated that if they were really active before their treatment that now that doesn't look the same, like they used to be able to walk a mile, no problem, or walk five miles or run five miles, no problem.
And just the grief and loss, even with that, and knowing that it is going to look very differently right now and finding what works well for them. And starting small, of even just a five-minute walk, and including family or friends or their spouse to make it a social activity, as well as being creative and finding something they enjoy.
So it's not necessarily like this structured exercise that feels overwhelming, and it can be hard to find this consistent level of movement, and I often see people that are going through that cycle of overdoing or underdoing, given their level of functioning that day or whether they're having a good versus bad day and along that time of treatment.
So it's just being creative and finding these small ways to stay active and noticing. I'll tell people, notice their mood and energy level before they do something and then noticing their mood and activity level after. And that can help with pushing themselves a little bit and finding those five minutes or 10 minutes a day of doing an activity.
Host Amber Smith: Prostate cancer may have side effects of incontinence or erectile dysfunction or other sexual issues. How do you address these with men?
Dorianne Eaves, PsyD: I tell people cancer affects a lot more than just the physical, and this is something certainly physical that is happening and a side effect of treatment, but it also bleeds into, and it impacts, their social functioning, their relationships, their intimacy. So seeing how it's impacting these and encouraging them to talk to their oncologists and urologists and finding treatment and medications and different things that can also help with these things, as well as therapy and things behaviorally that we can do that focus on the relationship and intimacy and finding different things that help with this, in combination with their medical providers. And different things like self-esteem and how it impacts their well-being, and understanding how this impacts them and their partners and maintaining that close, supportive relationship. And I think this is also when I can see couples as a whole and meeting them at their needs.
Host Amber Smith: Do you have some advice for how someone can help support a loved one who has a cancer diagnosis?
Dorianne Eaves, PsyD: I think it's meeting them where they're at. And oftentimes people try to understand or cheer them up, and a lot of times they might not want that. Just seeing what their needs are, meeting them where they're at and also knowing that -- I tell couples all the time -- that it impacts you very differently. You all are going through the same thing, but it's like you're reading the same book, but you're on different pages, and each of you have not read the page that the other one is on. So I think this is where I can come in and support them both, and finding ways, practical ways, of helping and supporting a patient.
And also knowing that a lot of times they still want to maintain their autonomy and their role within the relationship and their independence. So finding ways that they can still have that while also helping and supporting them along the way, too. And it might be, like said earlier, attending appointments with them, driving them to appointments and being that person that's taking notes and asking you the questions that the patient has so that the patient can be in the moment, too.
But it's a very difficult thing to come alongside someone that is going through cancer, cancer treatment, and a diagnosis. So just meeting them where they're at and supporting their needs. And also as a family member and caregiver, knowing that your needs are important to support as well.
Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Eaves.
My guest has been Dr. Dorianne Eaves, a psychologist from the Upstate Cancer Center's Psychosocial Oncology Program. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air": What is pelvic floor physical therapy, and whom can it help?
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Muscles in our pelvis may need rehabilitation because of injury or dysfunction. Did you know there's physical therapy designed for the pelvic floor? I'll talk about this with two doctors of physical therapy from Upstate who specialize in pelvic floor disorders. With me are Tania Gardner and Jillian Cardinali. Welcome to "HealthLink on Air," both of you.
Tania Gardner, DPT: Thank you.
Jillian Cardinali, DPT: Thanks. Glad to be here.
Host Amber Smith: Let me start by asking you to define the pelvic floor.
Tania Gardner, DPT: Well, the pelvic floor is a group of muscles in our body that sit in the base of our pelvis. They are unique in the sense that you are familiar with what your biceps are, your quadriceps, are muscles around your body that move your joints and help you move, but they're unique because of their location. They have some specific functions in that they close around our openings. So they help us deal with continence of the bowel and bladder. They are responsible for sexual function, and they also provide support. So they support our pelvic organs -- your bladder, your uterus, your rectum. And also, they work together with the muscles of our abdomen and our spine, and even our diaphragm to give us support and work as part of our core muscles. People talk about core strengthening. So, they make up that inner unit that really is the base of our stability in our body.
Host Amber Smith: And, Dr. Gardner, as you're explaining that, I'm thinking about muscles and how throughout our lives we do exercise to keep our muscles strong. But I don't know that I've ever done pelvic floor exercises. Is that what pelvic floor PT is all about?
Tania Gardner, DPT: It certainly is a large component. And you probably have done pelvic floor exercises without even knowing it. Your pelvic floor muscles are working when you're walking, when you're running, when you're doing strength training. And then there are some specific exercises that we work on, making sure that those muscles can contract and relax and lengthen. People are familiar with the term kegal muscles, or kegal exercises, and that often as what you think of, when you think of pelvic floor exercise.
Host Amber Smith: Well, Dr. Cardinali, let me ask you about the training for physical therapists who want to specialize in pelvic floor disorders. Is this something above and beyond becoming a physical therapist? Is this in addition to?
Jillian Cardinali, DPT: Yes, so, Dr. Gardner and myself actually teach an elective at the PT school. Some physical therapy schools will have somewhat of an introductory of what is pelvic floor physical therapy, but really to be a practicing pelvic floor therapist, these therapists are doing training outside of their doctoral PT degree. This is postdoctoral training. All of the therapists here Upstate have taken our training through Herman and Wallace Pelvic Rehabilitation Institute, which is an Institute that focuses primarily on training therapists and other individuals, including nurse midwives and occupational therapists to treat the pelvic floor. There are multiple institutions, though, that also do this training.
Host Amber Smith: So how would a person know that they need to see a pelvic floor physical therapist? What are some of the common diagnoses that you see?
Jillian Cardinali, DPT: Some of the common diagnoses we see include incontinence. That can be a loss of urinary, bowel, even gas outside of your awareness. It can be difficulty emptying, so it could be difficulty emptying the bowel or bladder, difficulty voiding. We do see patients for any form of pelvic pain. And then we see some more specific patient populations such as, patients who are pregnant or postpartum, and some postoperative patients, so possibly after a prostatectomy or after a prolapse surgery. So those are some of the most common diagnoses we will see.
Tania Gardner, DPT: And also I'd like to add, we do see children, or pediatric patients, and those include kids who are sometimes having bed wetting or daytime incontinence, or constipation - those are common diagnoses that we see. Kids sometimes can experience difficulty emptying their bladder. They can, have urinary incontinence or leakage during the day, they can have constipation, they can have fecal incontinence too. Sometimes those issues can arise from pelvic floor dysfunction. So just like with the other providers, usually the pediatrician or pediatric urologist or pediatric gastroenterologist will treat what they can treat and rule out things that are involved. And sometimes they are able to see that, this is a result of pelvic floor dysfunction. So, sometimes they have difficulty relaxing their muscles when they use the bathroom. And so then they aren't able to empty as well. And then they ended up having leakage later in the day. Or, a lot of times, kids are busy and kids are distracted, and they don't want to take the time to go to the bathroom. And because that occurs, their muscles actually will be in a shortened state and less efficient. So, we work on all those things to help them have better control and be more in charge of their bowel and bladder.
Host Amber Smith: It sounds like there's some psychology to this too, kind of mixed in?
Tania Gardner, DPT: Definitely. With, I would say with every population, I mean, because of the location of these muscles and some of their functions, they're not as easily discussed or understood. So there's some barriers sometimes with people seeking treatment because of that. But also, as Dr. Cardinali mentioned, when talking about bowel and bladder habits, a large part of what we do is education and understanding our patients, and making some behavioral changes sometimes can really help to go a long way for them.
Host Amber Smith: Well, Dr. Cardinali, you mentioned pregnancy, postpartum types of things. Do you also see male patients, or is this mostly for females?
Jillian Cardinali, DPT: We absolutely do see male patients. Males can also experience pelvic pain for a variety of reasons. And then, a large patient population that we see for males is males experiencing prostate cancer. So, the research has found that pelvic floor physical therapy is very helpful for those patients, especially if they're going to undergo a prostatectomy, which is the removal of the prostate. So we will see those patients before their surgery, as well as after their surgery to help with some of the symptoms that they might be experiencing due to this diagnosis.
Host Amber Smith: Let's talk a little bit more about which issues might arise in women, during prenatal, when they're pregnant, or after they've delivered. What types of issues are you able to help with physical therapy? Dr. Gardner?
Tania Gardner, DPT: Pregnancy is a really big event in your life. Your body goes through a lot of changes over the course of nine months. Regardless of how the baby comes out in the end, whether it's a vaginal delivery or a cesarean delivery, just the changes in your posture and the way that you move, the way that your muscles are lengthened. Many people go through it without any complication or trouble, but there are patients, too, that experience pain, whether it's pelvic pain, low back pain. In order to accommodate the growing baby, your abdominal muscles have to lengthen and separate. Everybody who has a baby experiences this. And then sometimes after delivery, it can require some specific retraining to help get that stability back, bring things back together. You may have heard of a term called diastasis rectus abdominis. That's a common thing. Sometimes, depending on the way the delivery goes, there can be injury during delivery, vaginal tearing. There can be soft tissue injuries. And a cesarean section is a pretty significant abdominal surgery. So a lot of those patients do well, even just a couple of visits to help them kind of regaining their strength, regain their stability and have the energy and mobility they need to take care of their new little baby at home, too.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Tania Gardner and Jillian Cardinali. They're both doctors of physical therapy, and we're talking about PT for the pelvic floor.
Dr. Gardner, is it common for you to see patients who complain of pelvic pain?
Tania Gardner, DPT: Especially in our current situation with a lot more people working from home, there is a lot more time spent on Zoom meetings or phone calls and things, and they're not moving around as much. And sitting can put a lot of pressure on your pelvic floor. In addition to that, I think we're all living in a very high stress environment right now. And when you mentioned that there's some psychology to this, a lot of people, you can see if they're stressed and their shoulders or in their ears, or you might recognize that you clench your jaw when you're really stressed. But so many people are holding their stress in their pelvic floor muscles. So they're having them in a shortened state. They're not really moving. And that can become really uncomfortable. I think we've even seen an increase in some of the referrals that we're getting of patients with pelvic pain, and that is across the board -- male patients with pelvic pain, female patients with pelvic pain, even kids are under a lot of stress. And I think that that plays a big part. So our job is to teach them where these muscles are in their body, teach them what they feel like when they are tightened and clenched, and what they feel like when they move and what they feel like when they relax, so that then they can better recognize when they are in those holding patterns, and kind of move past that pain and introduce some more movement into their day when able.
Host Amber Smith: How long does it take pelvic floor therapy to start making a difference for a patient, Dr. Cardinali?
Jillian Cardinali, DPT: During our initial evaluation, we always try to give our patients something that they can immediately begin to work on. So before they're leaving that first session, it might be something small, like trying to make a different bladder habit a part of their daily lives, or it might be an exercise, or even a stretch that they begin. It's very variable, I suppose I would say as far as the overall duration of therapy. It's quite dependent on how long their symptoms have been going on or if this is something new to them or if it's been going on for quite a while. But I would say we try to make some changes pretty immediately, even if that's small habit changes that can really make a big impact in someone's life.
Host Amber Smith: Are the exercises that a patient learns from therapy, are they going to be things that they can continue to do on their own, even after therapy's done?
Jillian Cardinali, DPT: Absolutely. So I always tell my patients that I try to build them a toolbox. So I want them to have, whether it might be exercises or good habits or something that they can always have to take with them and build on that. So of course, during the course of our treatment, I'm expecting them to make progress with their symptoms, but then they'll also have this toolbox, so that if something else comes up later in their life, they're going to be like, "oh yeah, I remember when I saw that physical therapist, she told me to do this," and they can bring that tool back into their life and begin to do that again. So for some individuals, that might be an exercise such as kegels. For others, it might be more of a stretch or a relaxation technique, maybe some yoga poses, or something that will help them with lengthening their pelvic floor muscles. And then, generally speaking, we do try to teach good bowel and bladder habits, so that I would say as a part of their lives. And hopefully they even share it with their family members and their friends, so we can continue to learn about good pelvic health.
Host Amber Smith: What are good bowel and bladder habits? Are you talking about regularity?
Jillian Cardinali, DPT: Oh, there are so many. So I guess my biggest tip, I would say, for our female population, is that when you're trying to empty your bowel or your bladder to please sit on the toilet. Have your feet firmly planted on the ground. So my tip would be, no hovering. If you're hovering, because you don't want to sit on the toilet, you're going to actually activate, you're going to engage your pelvic floor muscles. And when we empty our bladder or our bowels, we need our pelvic floor muscles to completely relax to allow those processes to happen.
Host Amber Smith: Interesting. That's a helpful tip. Well, Dr. Gardner, let me ask you, is a physician referral needed? Like, how would someone get physical therapy?
Tania Gardner, DPT: So in New York state, physical therapists do have direct access, which means that a patient can be seen by a physical therapist who has at least three years of experience for 30 days or 10 visits without a physician referral. Dr. Cardinali and I both work at Upstate, so we are under that Upstate umbrella, which is regulated by the DNV accrediting body. So, because of our institution, one of the requirements is that we do have a physician referral. And oftentimes these patients, because of the proximity of the pelvic floor muscles to the pelvic organs and some of the sensations that they're feeling, it is a good idea to see your physician first to rule out anything more sinister, to make sure that that pelvic pain really is coming from the pelvic floor muscles rather than something else.
Host Amber Smith: So it might be helpful to bring these issues up with a primary care provider first, and get their assessment of whether they should come for pelvic floor PT?
Tania Gardner, DPT: Absolutely. And oftentimes we find that patients will request pelvic floor physical therapy because they heard about it, that their girlfriend went through it, or their dad went through it after he had a prostatectomy, or they read a blog post on the internet and they heard about it. And most often, the physicians are very supportive and will honor that request, and they're able to just make sure that there's not something else going on. And when patients have their follow-up after having a baby and they follow up with their obstetrician or care provider, they're often able to get that referral then.
Host Amber Smith: Is there a phone number or a website that people can go to to learn more information about pelvic floor PT?
Tania Gardner, DPT: We have our upstate.edu website, and if you search for "pelvic floor physical therapy" on there, you'll be directed to our page. And our main phone number for scheduling appointments is 315-464-6543.
Host Amber Smith: Well, I want to thank both of you for making time for this interview. My guests have been physical therapists, Tania Gardner and Jillian Cardinali. I'm Amber Smith for Upstate's "HealthLink on Air."
What you need to know about hernia repair -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." More than 1 million hernia repair surgeries are done in the U.S. Each year. What can you expect if you or a loved one are facing this procedure? Today, I'm talking with Dr. Moustafa Hassan. He's a professor of surgery who also specializes in critical care at Upstate, and Maggie Wight, who is the Upstate Hernia and Abdominal Wall Reconstruction Program nurse coordinator. Welcome to "HealthLink on Air," both of you.
How many people contact the Hernia and Abdominal Wall Reconstruction Program each year, and what percent of those patients require surgery?
Maggie Wight: We typically see about 800 to a thousand patients a year on average, about 80 to a hundred patients a month. Of those new patients, 85% require surgery due to a known hernia, whether it's self-diagnosed or sent by a referring physician.
Host Amber Smith: So, Ms. Wight, I assume that as a nurse coordinator, you are probably the one speaking with all the patients. What are those first conversations like? And what sorts of information do you look for?
Maggie Wight: Our conversations begin with an introduction to the program and myself. The patient provides a brief explanation for their call, inquiring about services offered and an appointment requested. We accept self-referrals; we do not require a physician referral. I conduct a short interview with the patients gathering medical and surgical history. We discuss any recent studies obtained, such as images, bloodwork. The patient follows up with scheduling an appointment. Our location and direct patient line phone number is provided.
And the overall goal is to gather all the pertinent details so that when the patient meets with the surgeon, all the information is available and reviewed..
Host Amber Smith: Before they have the physical exam, are there other tests that they may end up needing to do or have before then?
Maggie Wight: The surgeon's physical exam is of vital importance. Paired with a patient's reported symptoms and their impact on their activities of daily living, then it's determined whether other studies are warranted. Further testing may be necessary based on the complexity of the hernia with a patient's medical and surgical history. Additional testing may include CTs (computerized tomography scans) or ultrasounds. Often a physical exam may be only required.
Host Amber Smith: Now, Dr. Hassan, if I understand correctly, a hernia is when organs protrude from their cavity, such as intestines coming through a weak point in the abdominal wall.
Does this happen abruptly, like in an injury, or does it develop gradually?
Moustafa Hassan, MD: That is a great question, Amber, because a lot of patients think that the hernia was brought about by a specific incident, and in a lot of cases, that is the case. But, there are many, many kinds of hernias, and they don't all have the same etiology, or cause.
So when we talk about hernias, we always like to split them up into two main categories. One of them is the inguinal hernia or the groin hernia that most people would assume that is the case when I talk about a hernia, but the bulk of our practice actually is what is known as incisional hernias and ventral hernias, which are hernias in the abdominal wall, following an operation that the patient had in the past. So, they're very different in the presentations. They are very different in the way we treat them as well. Inguinal hernias, which are the common hernias in the groins, usually just appear; they don't necessarily have an incidence prior to that period.
Some people have a predisposition, or the way their abdominal wall is structured allows that to happen. And it only becomes obvious when maybe they cough so hard or lift something heavy and so forth. So that is for inguinal hernias. As for the other ones, which are the common incisional hernias, there has been a scar on the abdominal wall.
This scar may not be strong enough, and it just gives way with time and allows a bulge to happen or a hernia to happen.
Host Amber Smith: Are hernias painful?
Moustafa Hassan, MD: So it depends: Some people may not even know they have a hernia, while others will present at the emergency room in extreme pain and complications -- strangulation, incarceration, which means the hernia gets stuck outside and they aren't able to push it back in. So there's a wide variety of symptoms, ranging from having no symptoms at all to having excruciating pain. In the middle are people who have pain when they do specific action or when they eat something and the bowel protrudes from the hernia, that brings about the pain.
Host Amber Smith: If somebody is not having any symptoms from a hernia, does that mean the hernia is not an issue that they need to see a doctor about?
Moustafa Hassan, MD: Well, I don't think so. I think a hernia is an abnormality. You don't want the first symptom to be severe pain or the complication that brings it to the emergency room.
So whenever there is a hernia, the patient needs to contact the primary care doctor or call the surgeon or just pay attention to it. Not every hernia needs an operation, but I think every hernia needs to be evaluated.
Host Amber Smith: When would a hernia be an emergency?
Moustafa Hassan, MD: A hernia would be an emergency if, basically, the intestines that stuck outside become actually stuck outside.
And there is pain, the inability to eat because the lumen (the opening or channel) of the intestine is obstructed, causing people to throw up and get distended. So that's obstruction or strangulation, which is basically a severe complication where the blood supply to that piece of intestine "got cut off or twisted and cut off. So that's a surgical emergency.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking about hernia repair with Dr. Moustafa Hassan and nurse coordinator Maggie Wight. And I want to remind listeners they can find more information about Upstate's hernia and abdominal wall reconstruction program at upstate.edu/hernia or by calling 315-464-1803.
And now I'd like to ask you about how the surgery is done. Which patients might be candidates for a minimally invasive approach to hernia repair?
Moustafa Hassan, MD: So when we talk about operating on people with hernias, we still have to split this decision to: Is this an inguinal hernia or is it an incisional hernia?
Because it's very different, and the treatments, like I said previously, are very different. Let me start by talking about the common, uncomplicated, or even complicated, inguinal hernias. It can be done through an open incision, or they can be done through a minimally invasive approach, which is nowadays, or at least since 2016, we've been doing with a robot. Almost every time most of the time -- I won't say every time, but most of the times we do the inguinal hernias with a robot. This is a minimally invasive procedure. Three little holes in the upper abdomen, no incision in the groin. And we fix it. We put a piece of mesh there, and it's an outpatient procedure, after which the patient goes home. The procedure itself takes between 45 minutes to an hour and 15 minutes, usually.
But of course it could be more complex, and it can take longer, or it could be more simple and take less. So that is for the inguinal hernias, either a robotic approach or an open incision, a robotic approach. The other big category, which is the incisional hernias -- these are different. These are big, big, abdominal wall incisions and reconstructions, after which the patient may stay in the hospital for a few days. Sometimes we have to remove a piece of intestine, if necessary. So it's a big undertaking. The smaller ones, the simple ones, can be still done robotically, a minimally invasive approach. The big ones are most commonly done through an open incision.
Not every patient is the same, and not every hernia is the same. So that decision is decided with the patient after viewing images and exploring the options and talking about what is a durable repair, which would restore function, comfort, good cosmetic appearance
Host Amber Smith: Is synthetic mesh, always used in hernia repair?
Moustafa Hassan, MD: For the most part, I would say, whether it's an inguinal hernia or an incisional hernia, we use meshes. This is the cornerstone of the repair. This is the way that we can increase the durability of the procedure and prevent hernias from coming back. They are not necessarily all synthetic meshes. There are some other products that work well, but the choice of mesh is very critical. It's based on the hernia and the patient and the situation itself. But most hernias are fixed with mesh unless they are really small.
Host Amber Smith: Do hernias ever recur after they've been repaired?
Moustafa Hassan, MD: Oh, definitely. There is a recurrence rate for the hernias, and this depends on the original hernia, was it fixed before, and also depends on the technique used, it depends on the experience of the hernia surgeon, and most importantly depends on the patients. So it's more common in people who are overweight, more common in people with uncontrolled diabetes, smokers, people who are immunocompromised, and then a few conditions that would predict whether the hernia would recur or not.
We actually do have a calculator that would predict the complications, including hernia coming back, and we would discuss this with every patient in our practice.
Host Amber Smith: So they know before they go into this what they may be in for.
Moustafa Hassan, MD: Very important to set the expectations, so people understand what they have and why the hernia they have is different from the neighbor's or the little tiny hernia of the groin that was fixed, never came back. So we have to really explain why not all hernias are equal and that the expectations also are not equal.
Host Amber Smith: Well, we've talked a lot about hernias. What is abdominal wall reconstruction? When would that be necessary?
Moustafa Hassan, MD: So basically it was very large hernias that had been fixed several times with subsequent loss of muscle tissue and so forth. We need to do more than just put a mesh in and close. We do an extensive, more extensive procedure if necessary, of course, to bring all the muscles and move them from the sides of the abdomen to cover the hole and bring them back together, reconstruct the abdominal wall.
Sometimes we have to move this large pad of fat that some people would have either had before, or they've lost a lot of weight and we still have that fat, or that is created by the hernia pushing over a long period of time. So we do a combined operation sometimes with with the plastic surgeons, who remove the fat, and we repair the hernia. It's more than just a hernia repair, so we call it abdominal wall reconstruction, but realistically speaking, you can call any large hernia repair an abdominal wall reconstruction.
Host Amber Smith: What is recovery like for someone who has a hernia repair? How soon do they anticipate they can get back to normal activities?
Moustafa Hassan, MD: It depends on the kind of hernia, and, Maggie actually runs a rehabilitationprogram, an after-surgery rehabilitation program, and she can elaborate on that.
Maggie Wight: Our team has developed a successful prehabilitation and postoperative rehabilitation program to prepare for surgery. We focus on optimizing physical and life preparation to improve function and health before repair. We provide access to a free mobile app and website, which breaks down our programs into three categories: before surgery, surgery and after surgery. Familiarizing yourself with tips that will help develop good habits that can promote healing, improve flexibility, teach proper breathing techniques and safe ways to bend and lift are among a few of the benefits.
Our program focuses on including self-care for healing and recovery, stretching activities of daily living, exercises to enhance your repair and impact your recovery. As well as weight loss, smoking cessation and blood sugar control. As the nurse coordinator, we work in close contact to monitor your progress and success and ensure your preparedness for surgery.
Patients are instructed to call with any questions or concerns or changes in their symptoms before surgery. And then we will move forward with scheduling. As far as recovery, our postoperative rehabilitation program is designed to maximize a complete recovery and healing process to regain their independence and ensure durability of their repair.
After being discharged from the hospital we encourage that you'll be able to go upstairs, that you walk frequently and stay very active. We ask that you avoid any heavy lifting for about three to four weeks for an inguinal groin hernia, and about six to eight weeks for an abdominal ventral hernia.
We typically don't like to put a number on weight limit restrictions because "heavy" varies from individual to individual. Therefore, we ask that you use your good judgment and avoid any unnecessary abdominal strain during that time frame, which can happen even without lifting anything, simply by bending over or transferring positions incorrectly, which is why it is imperative that you participate in our prehabilitation program so that you understand these tips beforehand.
We ask that after surgery, you take over-the-counter medications, such as Tylenol or ibuprofen, if not contraindicated, for first-defense pain control and reserve prescribed narcotics for breakthrough pain. That, paired with our exercises and the knowledge that you gain from the rehabilitation program, sets you up for success, through recovery.
Host Amber Smith: Well, I appreciate both of you making time for this overview.
My guests have been Dr. Moustafa Hassan, a professor of surgery in the Upstate Hernia and Abdominal Wall Reconstruction Program, and the program's nurse coordinator, Maggie Wight. I'm Amber Smith for Upstate's "HealthLink on AIr."
Here's some expert advice from Dr. Kaushal Nanavati, from Upstate Medical University. What's the best way to spend a mental health day?
Kaushal Nanavati, MD: You know, the best answer in medicine is, it depends. The reason I give that answer is because for some people it might be getting to the bank, and getting their finances done. Others might need to go grocery shopping or do the lawn. Some people might need to just take a nap, right, sleep? Others may feel like, you know what, I would like to get out into nature and go on a hike.
Now sometimes people do physically challenging things during down times, and it's rejuvenating in the moment, but the body does require recovery, right? So the weekend-warrior phenomena (that) can actually potentially even lead to injury. And so the key is consistency and trying to pace ourselves. One study was interesting that showed that people that did 10 minutes of exercise a day, versus people that did 30 minutes three times a week -- the people that did 10 minutes a day were more likely to make it a habit.
And so again, this idea of recovery, and then, going, going, going, going until you hit the wall and then taking a break, versus incorporating into a regular routine, which you can sustain over time, leads to improved, sustainable outcomes. So that in all spokes, you're able to perform at a better, more consistent level, as well.
Host Amber Smith: You've been listening to Dr. Kaushal Nanavati, a doctor of family medicine and the assistant dean of wellness at Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate’s literary and visual arts journal, The Healing Muse, with this week’s selection.
Deirdre Neilen, PhD: Eric v.d. Luft is a poet, author, editor, professor and publisher who owns Gegensatz Press in Syracuse, New York. He sent us a lighthearted look at a different kind of bucket list. Here is "Now What?":
Done everything I wanted to do,
Seen everything. I wanted to see,
Gotten everything I wanted to get,
Been everywhere I wanted to be.
So now what?
Crawl toward death?
Slink into nothingness?
Fade into shadows?
Just sit around and rot?
I've done my job,
Achieved my goals,
Fulfilled my vocation.
So what else is there?
Bought my gravesite,
Prepaid my funeral,
Prepared the way
For easy passage.
If I were
A veterinary patient,
I could at least expect to be put down
While human lives are mercilessly prolonged
Beyond their time.
I think instead
I'll start all over
With childlike wonder,
Learn everything anew,
And once again
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": preventing cervical cancer. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.