Understanding Pelvic Floor Health and Rectal Prolapse with Dr. Brooke Gurland

In this episode, host Rachel Baker speaks with Dr. Brooke Gurland, a Clinical Professor specializing in colorectal surgery at Stanford University. Together, they explore the world of rectal prolapse and the importance of pelvic floor health.

🩺 What You’ll Learn:

1:15 - Dr. Gurland's Journey: Her transition from general surgery to colorectal surgery

2:45 - Understanding Rectal Prolapse: Subtypes and prevalence among women

4:30 - The Role of the Pelvic Floor: Anatomy explained

6:00 - Treatment Options: Non-surgical interventions and surgical techniques

8:15 - Importance of Patient Education: Creating animated videos for better understanding

10:30 - Research and Leadership: Dr. Gurland’s role in the Pelvic Floor Disorders Consortium

12:45 - Mentorship and Mindfulness: Insights from her mentor and personal philosophy

Join us for an informative discussion that sheds light on an often-overlooked aspect of health. Dr. Gurland’s expertise and innovative approach to patient education are making waves in the colorectal community!

🔗 For more information about Dr. Gurland’s work on Patient Education Videos.

🔗 For more information on the Pelvic Floor Disorders Consortium.

🔔 Don’t forget to like, share, and subscribe for more insights from the Stanford Department of Surgery.

Gurland-Scrubcast

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Brooke Gurland. Welcome to the show.

Brooke Gurland: Hi! Hey, Rachel. Thanks for having me.

Rachel Baker: Dr. Gurland is a clinical professor in our Division of General Surgery's colorectal section.

What is your colorectal surgery origin story?

Brooke Gurland: Well, great question. So, you know, you start in general surgery in many cases, and then you kind of branch out once you're in general. And I've been practicing for about 24, 25 years. And yeah, I've been here for a while. And, um, I, you know, really just started I basically love the operating room.

And then once you know that you love the operating room for anybody who's just considering what they want to go into it, then you kind of narrow it down to kind of upper [00:01:00] versus lower. And one of the, the, um, fun things about colorectal surgery is that there's a large diversity. You know, you could be do big abdominal cases.

You could choose to focus on cancer. You can also do a lot of anal rectal conditions. Colorectal talks all about function. You know, like, uh, one thing is the anatomy, but, like, how people are dealing with their bowel habits, which, you know, people love to talk about. They're on vacation. That's, that's what comes up.

Rachel Baker: One of my favorite books when I was little, Everybody Poops.

Brooke Gurland: Exactly, exactly. So, colorectal surgery is fun. You can do endoscopy. So there's a lot of diversity.

Rachel Baker: Awesome. Well, so you specialize in rectal prolapse, which apparently is not a homogenous diagnosis. There are different subtypes.

Brooke Gurland: So, right. I do a lot within colorectal, but I've kind of made my niche in this, uh, idea about prolapse and also multi compartment prolapse, which means that it can just happen to the rectum, but it can [00:02:00] also happen to the other organs.

And primarily we're discussing women and we're talking about pelvic organ prolapse and urinary incontinence and actually in the world of rectal prolapse, about 90 percent affected are women and about 10 percent men. Wow. And so that's what I've made my area of, you know, kind of outcomes research and learning more about it and surgical techniques and education.

Although I do many things, that's where I like to kind of stay focused in the research arena.

Rachel Baker: Any idea why so many more women than men?

Brooke Gurland: So there's two kind of main areas we think about one is a young group who hasn't had any child birth and the other is a group of women who are more around the perimenopausal period more common like after 50s and that is usually more related to So, in the younger group, we think more along the lines of like hyperreflexia, which is those hypermobility kind of disorders, Ehlers [00:03:00] Danlos, something related to connective tissue disorders.

And that's kind of a branching out. I'm probably even being too specific with EDS. We call them hypermobility. It can also be a lot of chronic straining in the younger groups, um, eating disorders. And we know that there's trauma can also be related. And then in the, in the older group, we blame a lot on childbirth, but there are probably other things that also are adding to weakening the pelvic floor and some lifestyle things that one could work.

Rachel Baker: Okay. I didn't know that I had a pelvic floor until I took yoga. Uh, what is, what is my pelvic floor? We're going to decide.

Brooke Gurland: We are a Bondi kind of thing. And you have to pull it. And now it's like, I like to give an example of like a paper bag or a shopping bag, right? So in a shopping bag, there's something on the bottom of that shopping bag that has to support.

And sort of, if you think of it that way, there's a series of pelvic muscles and nerves. And they will support the organs that then [00:04:00] come through. And if you do them in sort of a sequential order from front to back, you're talking about, you know, the urethra that helps you urinate, the vaginal, the vaginas and that middle compartment.

And then in the posterior, the behind compartment is the rectum. But it's the same muscles and the same nerves, and they are subject to different degrees of injury. So if those muscles were too tight, and when I say too tight, I mean, like, let's say you're a type a person and you're like, all the time, you never relax, then you can have problems urinating, defecating, you can have pain that's associated, or if you're someone, let's say you've had some sort of injury or childbirth, they could have had radiation surgery, but that area is loose, those pelvic muscles are loose.

Weaker or as we age, we know that muscles become weaker. So in anything, if things are too loose, then that can lead to any kind of incontinence.

Rachel Baker: Okay, so say I'm too loose or whatever. Um, [00:05:00] Can you help me? What do I do?

Brooke Gurland: Yeah, so that's where that's where Pelvic floor exercises can come into play. That's why it's so important for all Individuals as they age to be very active Right to do a lot of walking and there's a lot of data on that as far as lifestyle we don't tend to think of how that interplays with the pelvic floor, but it certainly does and in the older population there's a relationship between nursing home admission and incontinence rates and some of it may be like as you're Become incontinent.

It's harder for your family to take care of you. But it's the same thing if you can't get up from a chair You're not mobile. You can't get to the bathroom all of those things that lower pelvic You're not using those areas and it becomes harder and harder to like to get around and take care of your own Lifestyle, so I know we jumped around a lot Rachel about the younger the older the pelvic floor But those kind of those things all interplay.[00:06:00]

Rachel Baker: Got it. Okay, so Taking care of my pelvic floor, but let's say the worst happens and I end up with a prolapse. What are the is it surgery?

Brooke Gurland: So, um. Is that where you come in? Yeah, so in the world of rectal prolapse, there can be like internal rectal prolapse, external rectal prolapse, and then it depends on what the symptom is.

is like what it is that's bothering you. This is a quality-of-life issue. It's not life threatening. It doesn't have to be taken care of. But in most people, we're going to recommend it and say yes, because if you have a significant prolapse, that means that something is hanging out.

Rachel Baker: It's loitering.

Brooke Gurland: It's loitering.

Yeah. It's coming out of the anal muscles opposed to you could have the rectum bulging into the vagina. And we call that a rectocele. We're almost like pockets because of the direction of forces. That's actually pretty normal finding only when it becomes larger than a certain size that we think about it.

But when I think about a true rectal prolapse, I think of it [00:07:00] coming towards the anal muscles or out of the anal muscles. And the reason that we do want to treat it in people who are healthy enough, who want. to have it treated is because over the long-term it can stretch the anal muscles. It can put traction on the pelvic floor and cause nerve injury.

And so even if you start out and your function is good and it only comes out intermittently over time, if it constantly coming out, it can make the function of the bowel. That would mean either difficulty getting the stool out. Or making it so that you leak stool. So we want to avoid that happening long term.

Rachel Baker: Absolutely.

Brooke Gurland: So then yes, surgery. Yes, that's where I come in as a colorectal surgeon. That's where I say, Oh, let's let me make sure you don't have what I call multi compartment prolapse. That the vagina, the bladder, all that is intact. Because we want to make sure that we've evaluated the whole pelvic floor.

And then yeah, surgery. If people are interested, but there are exercises and things that can be done first, [00:08:00] always believe in optimization. Optimization means that your diet is right. And your exercise is right. And you're doing all those lifestyle things.

Rachel Baker: What kind of operation do you do? Is this like a laparoscopic procedure or is it open? Robotic?

Brooke Gurland: I think we've moved towards the world of trying to avoid open. in most individuals unless there is a reason why they can't have a minimally invasive procedure.

Rachel Baker: Okay.

Brooke Gurland: So the answer is minimally invasive, which is either robotic or laparoscopic. And I tend to do most of my cases robotically.

One of the operations involves a lot of sewing low down on the pelvis. That's where you really get the advantages of the robot because it really allows you that wrist and movement and very easy to sew there.

Rachel Baker: Awesome. Well, so, um, one of the things that actually I think I know you best for is your interest in video.

One of the things that you sent to me was this animated video for patient education. How did you come up [00:09:00] with the idea of creating an animation and why a video for patient education?

Brooke Gurland: I'm of course interested in how patients do and their outcomes and the individual, but those that getting those kinds of numbers takes really long time period.

One year is not enough, maybe five years following people up and, and we're doing all of those things. So just so you know, like in the back burner here, we're constantly capturing outcomes and trying to do loader center things, but they take a long time.

Rachel Baker: Yep.

Brooke Gurland: And then what I started to think about is like, okay, well this is.

What's I want to know? Like, these are things I want to know, but like, how can I really help the patient, how can I make it easier for them to understand what's going on? And we just live in a world of video. Now we live in a world of short videos. I'm super interested in how to facilitate that communication.

Um, there's so many different kinds of learners and visually we see things differently. Like even, uh, I don't know, five years ago, Rachel, don't [00:10:00] you think that we create our content differently now than we did before? And that's where I became interested. It was like a beyond what I could do with my own video.

And really, I actually started. Stanford video has been involved with helping me create some of them and my first videos were more along the lines of explaining to patients what their anatomy was like. And I have two, one is, uh, showing the, um, an internal prolapse, external prolapse and the defecation.

And then there's another one that talks about what we call dysnergic or difficult evacuation. And so we spend a lot of time on those first two. And ultimately we have in the works now that we'll be live at some point, video making is kind of like renovating a home. It just always takes longer than you think.

Rachel Baker: Always,

Brooke Gurland: always, always. Yeah. So, um, that we're going to do one on the surgical techniques. So our next one will be all specifically about surgery, but we started about just teaching people about their anatomy, why they have what they have, um, because the [00:11:00] health literacy, even in very educated people. Is very low like you didn't know you had a pelvic floor until yoga and we don't know what that pelvic floor does and Well, we don't understand what's happening with our bodies.

It's a source of anxiety You know, what is normal? What is not normal? And sometimes I feel like my job is just explaining to people what's happening on the inside I can't necessarily fix everything and some things you just have to fix on your own, but you have to be able to relax and accept and you know, many things you have to work on by yourself is what it comes down to.

Rachel Baker: And do you find that the patients are responding to these videos?

Brooke Gurland: I think so. I hope so. So one of the studies that I think I sent to you that we recently got published, we did kind of a focus group. That's how I looked at it. We sent the video out to a lot of the patients who already were participating in my registry, and we gave them the opportunity to do a one-on-one video.

And then we did some qualitative analysis. And that's where I said, like, I can [00:12:00] develop content. But that isn't necessarily content that patients want to see. So I spent a lot of time sending it out to women of different age groups to making sure that I'm capturing like what they want. And then we did this subsequent video, we implemented some of those changes.

And now when I go to do the surgery video, I'll do that. But really like people have to tell me what resonates with them. You want to hear something that was interesting? Um, someone commented on my voice or my narration and I know I have to work on that.

Rachel Baker: Yeah. So funny.

Brooke Gurland: I know. But yes, I want to develop things that patients want to hear.

And that's why we did a lot in, um, different translations. So we translated it into Chinese, into Korean, Portuguese, Spanish, Arabic, and I would keep translating it. I think. Women with this problem need to see the content and the language they are comfortable with.

Rachel Baker: That makes sense. Also, it's funny, you said that you are a person who loves [00:13:00] So it is always a little surprising to me when people who love to operate take leadership positions because I think that takes them away from the OR.

You are chair of the Pelvic Floor Disorders Consortium, which is part of the American Society of Colon and Rectal Surgeons, and you've been working on creating a research agenda for like, The next five to 10 years, which is a massive undertaking. I don't even know, where do you begin on something like that?

Brooke Gurland: I know, right?

Rachel Baker: It's like super amorphous.

Brooke Gurland: Yeah. So, um, it's been a great time working on this committee. Like it's part of the pelvic floor committee. And then the consortium was sort of a natural movement and we've created a number of projects, especially around rectal prolapse. We've done a lot of publications.

And then I said, whoa, whoa, whoa, let's now we've. We've like thrown out all these tentacles. We've done all these projects. And I mean, international, you know, I have surgeons all over. We're looking at time zones. Last year was pelvic floor physical therapy [00:14:00] with work group and everybody would work together on their own.

And then they would come together at the end of the year at the national meeting. And then we would vote. What do we think is important? What isn't? And we've got publications coming up. So what we did with this project is we did it as a four round Delphi. And that meant that the first round was I sent out to this very large volunteer group What do you think are the things that we should focus on?

Where do you see this going? And then they sent me back all of these topics I then put them into themes we categorized and then we sent out a three round delphi until we narrowed things down at the meeting itself We then voted on the ones that were in intermediate consensus, like if it made high consensus, then we said, okay, well, that's great.

We leave it. But if it was intermediate consensus, we then revoted on it. And then we came up with taking the consensus statements. And then saying, how do we actualize these into [00:15:00] projects and the other next big piece of it. And we have that also like on the website is we created a survey for patients. So we took all the topics.

It's not just surgeons, by the way, it's pelvic floor, physical therapists and urogynecologists and anybody who works in the space radiologists GI. And so we said, okay, these are the ones that the clinicians were interested in it. Now you as patients tell us. What you are interested in. So actually our IRB is only for the United States, and I've been a number of sites that are Translating a site in Brazil or waiting for their IRB So we're gonna also look at it not just as all patients and English speaking patients, but patients in different countries Does everybody want to know the same thing or do they want us to focus on other things?

And I feel like that will be super helpful when we are requesting grant money or we're trying to organize ourselves. And then it, it kind of gives us like, Hey, we asked all these questions, we looked at it, and now this is the direction that we need to go. [00:16:00]

Rachel Baker: Awesome, I love that. Uh, well, so we are at the point in each episode of Scrubcast where we ask our guests the two same questions.

And the first one is, Who is a surgeon you admire and why?

Brooke Gurland: I most recently came back from a retirement party of one of my real mentors, Tracy Hull. She actually won a mentor award at the ASCRS. And prior to me being at Stanford, I was at the Cleveland Clinic and she was one of my partners. And she's just a huge role model.

You know, she's fantastic. Like the women group that are about 10 years, maybe 15 ahead of me, they really paved the way for ease of women in the fields of colorectal. So I'm super excited to see what she's going to do next because that's how I'm going to model what my retirement looks like.

Rachel Baker: Awesome. Uh, the second question is the best advice you have received in 10 words or fewer.

Brooke Gurland: I think the best advice is [00:17:00] when we talk about this idea of mindfulness. And just working on one thing at a time. And I know we like have all these lists, and all these things that we have to do. And I think that makes us a little bit crazy. And I think when I have a day like I'm doing this podcast, like this may be the only thing I'm going to do today.

I'm not joking. I've already done a number of things. But, but instead of me trying to do everything all at once, it's just, okay, I'm allotting a time. This is what I'm working on. I'm not trying to answer a million phone calls. I'm not trying to check email. I really moved away from the, that concept of look, what a great multitasker I am.

I can do everything. That is not fun for me. I think we really should move towards one project at a time. You're eating lunch. Just eat lunch. Just eat lunch.

Rachel Baker: Yeah, be present, enjoy, savor your food. Yeah. Well, it has been an absolute pleasure chatting with you, but before we go, I want to ask, what is next for Dr. Gurland?

Brooke Gurland: Oh, I [00:18:00] don't know. You know, there's so many projects that I have to wrap up and do. Actually, the next thing that I'm looking forward to in February, which I think, Rachel, you would be interested in, is I'm taking a culinary medicine class.

Rachel Baker: Ooh, awesome. Yeah. That'll be so much fun. I can't wait to hear more about it.

All right. Well, thank you so much.

Brooke Gurland: Take care.

Rachel Baker: Okay. You too.

Brooke Gurland: Bye.

Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrubcast is a production of Stanford university's department of surgery. Today's episode was produced by Rachel Baker.

The music is by Midnight Rounds. And our chair is Dr. Mary Hawn.