Leila Neshatian, MD

You laugh, you pee. This is the reality for many middle-aged women, especially if they gave birth vaginally. If it’s just a few drops, it’s usually no big deal. But sometimes it’s not just a few drops. Then there is the flip side of the coin — fecal incontinence. Now we are getting into territory so taboo and embarrassing that people do not even want to bring it up with their physicians.

Pelvic Health Problems — Embarrassing and Undertreated, Patients Suffer in Silence

Pelvic health is fundamental to good quality of life. Nevertheless, comprehensive multidisciplinary care in this area can be hard to come by. That’s why patients travel from all over the country to receive the kind of specialized care given by Leila Neshatian, MD, in collaboration with a team of dedicated clinicians who work alongside her at the Stanford Pelvic Health Center.

While the Pelvic Health Center serves all genders, the majority of patients are women of middle or older age suffering from a wide array of pelvic floor disorders. These conditions negatively impact quality of life with symptoms such as urinary and/or fecal incontinence, constipation, and pain or pressure in the pelvic area. It is not unusual for the center’s patients to have a long history of being dismissed or undertreated elsewhere. The unfortunate reality is that anorectal and pelvic health is not covered adequately in many medical training programs, so physicians simply aren’t equipped to handle the problem. They may recommend Kegel exercises or, in more severe cases, refer patients for surgery, but that is about the limit of their options.

Finally, a Comprehensive, Multidisciplinary Solution

The Stanford Pelvic Health Center, on the other hand, provides coordinated, multidisciplinary care that includes the specialties of gastroenterology, colorectal surgery, urogynecology, urology, pain anesthesiology, and physiotherapy. Neshatian, clinical associate professor of gastroenterology and hepatology, specializes in neurogastroenterology and benign anorectal disorders. Her patients receive a comprehensive evaluation, including assessment of anorectal function, coordination, and sensory function via high-resolution anorectal manometry, as well as three-dimensional dynamic ultrasound to evaluate the anal sphincter and surrounding muscles, and magnetic resonance imaging defecography to dynamically visualize overall pelvic organ structure and function.

Following this assessment, the multidisciplinary team works together to determine the best multipronged treatment course. “We offer comprehensive medical management, physical therapy, and combined surgeries,” says Neshatian. By “combined surgeries,” she means that two surgeons, one colorectal and the other specialized in urogynecology, may operate on a single patient during the same surgery to ensure that all the pelvic issues are addressed at once by the most experienced hands.

Leila Neshatian, MD

Innovative Research in Pelvic Health

In addition to seeing patients, the Pelvic Health Center conducts innovative research into an aspect of health that remains poorly understood, so that physicians all over the world can better treat their patients. For instance, Neshatian and her team are working to identify specific targets for measures of pelvic health, such as the size and quality of the skeletal muscles, that must be achieved in order to treat or prevent pelvic symptoms in aging women.

One important learning from her research is the importance of muscle size and quality, not just in the pelvic area but overall. “In order to have better pelvic health, you need better muscles,” says Neshatian. “If the person is deconditioned, the muscle is replaced by fat, and the likelihood of having these problems is certainly higher. We proposed that if we put women through physical activities, such as resistance training, to improve overall physical conditioning, symptoms related to pelvic floor dysfunction such as fecal and urinary incontinence will improve as well.” Research is currently ongoing to evaluate this hypothesis.

This is a unique educational opportunity because, to be honest, anorectal and pelvic training is missing from many programs.

— Leila Nehastian, MD, clinical associate professor of gastroenterology and hepatology

In a particularly innovative project, Neshatian and her team will be examining the relationship between pelvic health and the microbiome. “We know that the microbiome changes in patients who are frail,” she explains. “This becomes a vicious cycle in terms of the microbiome causing frailty and frailty changing the microbiome. We think that because frailty can lead to pelvic pathologies, by changing the microbiome, you can prevent frailty and therefore improve pelvic health.”

They would also like to determine how the physical therapy that they offer at the center improves symptoms, looking specifically at how it produces changes in overall muscle strength and whether it affects the microbiome. Findings of this research should be available in the next few years, which will give treating physicians around the world new information and tools to use with their patients.

Training a New Generation

Given the unique nature of the services provided and the research taking place at the Pelvic Health Center, training is an important component of the program. A clinician educator, Neshatian is GI program director of the Neuro-Gastroenterology Fellowship, which includes training at the Pelvic Health Center. Others who receive training at the center are medical residents as well as fellows in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and Gastroenterology. “This is a unique educational opportunity because, to be honest, anorectal and pelvic training is missing from many programs,” she says.

The need for and interest in a comprehensive approach to pelvic health is so great that there are plans to expand the Pelvic Health Center, with a move to a larger space in Pavilion E anticipated in the near future. This will provide the space they need to increase their clinical staff and ultimately help more patients.