Whether treating chronic pelvic pain that interferes with daily function or finding better biomaterials to help women experiencing prolapse, the Division of Urogynecology & Pelvic Reconstructive Surgery is bringing a fresh look to issues that significantly impact the quality of women’s lives across the lifespan.

“We are in a very exciting time for the Division of Urogynecology and Pelvic Reconstructive Surgery. Pelvic floor disorders encompasses a broad array of conditions in impacting female pelvic health, which traditionally have been undertreated and underrecognized. This group of faculty is poised to really change that by placing female pelvic health front and center,” said Pamela Moalli, MD, PhD, the division’s new director. “The faculty we have hired over the past several years have brought in a huge amount of talent. They make my job very easy in that they are hardworking and extremely motivated to improve women’s health. Moreover, we’ve managed to identify a niche for each of them to explore and expand, which has vastly broadened our expertise and the services we provide.”

Among the faculty members who joined the division recently is Jocelyn Fitzgerald, MD, who focuses on pain disorders in the pelvis. Dr. Moalli served as one of her mentors when she was in Pitt’s Physician Scientist Training Program. Dr. Fitzgerald began studying pelvic pain as an undergraduate majoring in women’s studies and neurobiology; she learned that women process pain differently, and their pain often winds up overlooked by providers.

“There are so many layers to women’s pain; it’s very non-organic. No one outside OB/GYN has any training in it,” Dr. Fitzgerald said. When CT scans and swabs come back negative, many women are told that the pain is psychosomatic.

On average, a pelvic pain patient endures seven to eight desperate doctor’s visits before a diagnosis: “there is little research and no clinical haven for these women,” said Dr. Fitzgerald. “It’s this vicious cycle.”

Acute trauma upregulates the neuroimmune system, making the pain response much worse; pathways in the brain and spinal cord become hypersensitized, and all nerves in the pelvis overlap, complicating the diagnosis. Endometriosis can create neighboring pain in an inflamed bladder, for example, or gastrointestinal pain, though to the naked eye, nothing seems wrong.

“The female pelvis is designed to hide stuff,” allowing women to carry children, Dr. Fitzgerald said. “But it also gets derailed very easily.” To provide the care that these women need, the division opened the Chronic Pelvic and Bladder Pain Clinic at the UPMC Lemieux Sports Complex in Cranberry, Pennsylvania. An extension of the Chronic Pelvic Pain and Endometriosis Center, the clinic opened at the beginning of April 2021 and is already outgrowing its capacity.

The concept is that by offering medical intervention (which includes physical therapy and cognitive and behavioral health services) before pain becomes centralized, women won’t wind up in that vicious cycle.

Patient feedback about the clinic has been overwhelmingly positive, Dr. Moalli said, which has been gratifying for the division’s staff.

“Pain in any sort of medical practice is always very hard on doctors. You want to do something to help the patient, and often it’s difficult to treat them,” she said. “I’m really happy that we have a highly qualified physician who has created a product based on evidence that has been really life changing for these women.”

As the largest academic uro/gyn division in the country, research among doctors has been robust. Initiatives include developing new biomaterials to improve outcomes in disorders such as prolapse and incontinence; understanding recurring urinary tract infections in older women with the goal of creating better protocols that limit antibiotic use; and developing robust biomimetic models for teaching surgical residents and fellows using minimally invasive surgical techniques such as laparoscopy and robotics. Amanda Artsen, MD, MSCR is studying how patient factors impact outcomes following the placement of a biomaterial.

oSarah Napoe, MD, MS, studies health-seeking behaviors among women and what barriers prevent them — particularly women from underrepresented minority populations — from seeking treatment.

“One of the things we noticed is that the population of patients we see is not sufficiently diverse and certainly not representative of the women of Pittsburgh. We know that patients are more likely to seek care from providers who look like them and/or share a similar culture. Improving the diversity of our providers and the patients we see will positively impact the care we provide,” Dr. Moalli said.

When she was a medical student at Pitt, one of Dr. Napoe’s mentors was the late Morris Turner, MD, who was renowned for his work in Pittsburgh’s Black communities. She recalled that he made her promise to return to Pittsburgh to continue this work, and she did.

“I think I am fulfilling that promise,” said Dr. Napoe, who also serves as the new ombudsperson for diversity in the Obstetrics and Gynecology Department at UPMC Magee-Womens Hospital. Her role is to help students experience a positive, welcoming environment, and one of her goals is to help diversify the hospital’s provider pool. Recently, Dr. Napoe also received a grant from the Pelvic Floor Disorders Research Foundation to study “Black Women’s Experiences with Urinary Incontinence.”

Another of the division’s key initiatives is the new MOMMA Postpartum Healing Clinic, led by Lauren Giugale, MD. (The name comes from StreaMlining and OptiMizing MAternal pelvic floor health after childbirth.)

The clinic, which opened Nov. 1, 2020, offers focused consultation for women with third- and fourth-degree lacerations or other complex obstetrical injuries and peripartum pelvic floor symptoms. Eventually, the clinic’s goal is to offer collaborative consultation and evaluation for women with any postpartum pelvic floor disorders within one year after delivery.

“We know that certain types of lacerations that occur within childbirth are associated with an increased risk of complications” such as pain, urinary or bowel symptoms, Dr. Giugale said. “It made sense to offer this kind of care at Magee because we have 8,000 to 9,000 deliveries per year.”

Between 75 and 80 percent of first-time mothers sustain some kind of tear during childbirth. And while only 2 to 5 percent are severe, all women could benefit from more pelvic floor[1]specific questions between one and three weeks postpartum, Dr. Giugale said.

In addition to more specific questioning and examination of the birth injuries, the clinic may refer patients to physical therapy, determine if antibiotics are needed, or conduct an ultrasound of the pelvic floor, a technique in which Dr. Giugale is training. Because pelvic floor prolapse and stress urinary incontinence are so closely linked to maternal birth injury, Dr. Moalli’s hope is that the clinic’s more proactive approach will have a positive impact on patients later in life.

“To me, understanding the pathophysiology so we can implement preventive measures is really the key to the puzzle,” she said. “That, we believe, will put Magee at the forefront in reducing maternal birth injury and, as a result, future pelvic floor disorders.”