Referral patterns for pelvic floor disorders

Introduction and hypothesis  

To determine referral patterns to the gynecology directorate for symptomatic pelvic organ prolapse and urinary incontinence     

Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic

Objective To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC). Method Retrospective cohort study, patient satisfaction questionnaire. Sample: Secondary and tertiary referrals with complex pelvic floor disorders. Main outcome measures: symptom clusters and treatment received; patient satisfaction. Results A total of 113 new cases over a 3‐year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension‐free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory. Conclusion Combined PFCs led to a more pragmatic approach in treating patients’ symptoms. Combined surgery was undertaken in one‐fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.     

Multidisciplinary management of pelvic floor disorders

Pelvic floor disorders are being diagnosed in women with increasing frequency. Disorders of the different compartments of the pelvic floor (anterior, middle, and posterior) often occur simultaneously. A multidisciplinary approach is often needed to pursue the proper workup and reach the optimal treatment regimen. Pelvic floor centers are emerging as a model in which to treat these complex patients. Lastly, we will highlight case examples of how a pelvic floor center can be beneficial to the workup and management of these patients.     

Pelvic floor muscle function in women presenting with pelvic floor disorders

Introduction and hypothesis  This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. Methods  Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. Results  The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. Conclusions  Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.     

Spanish language translation of pelvic floor disorders instruments

The purpose of the study is to translate existing measures of pelvic symptoms and quality of life from English into Spanish, facilitating research participation of Hispanic/Latina women. The forward–backward translation protocol was applied then adjudicated by a concordance committee. The measures included the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), Medical, Epidemiological, and Social Aspects of Aging (MESA) Questionnaire, Hunskaar Severity Measure, Fecal Incontinence Severity Index and modified Manchester Questionnaire, Pelvic Organ Prolapse/Urinary Incontinence Sexual Functioning Questionnaire (PISQ), and the Life Orientation Test (LOT). English and Spanish versions were administered to 50 Hispanic/Latina women with pelvic symptoms. Kappa correlations of items and correlation coefficients for scales were computed. Psychometric testing for translations demonstrated good (0.80–0.89), very good (0.90–0.95), or excellent (>0.95) correlations for primary scales of the PFDI, PFIQ, MESA, Hunskaar, PISQ, and LOT. Strict translation techniques and testing yielded valid Spanish translations of instruments assessing pelvic symptoms/functional life impact in women with pelvic floor disorders. Electronic supplementary material The Spanish translations of the instruments discussed herein are available as Appendixes 1-7 in the form of electronic supplementary material and can be found at http://dx.doi.org/.     

Sexual health of women with pelvic floor disorders

Preemptive analgesia in vaginal surgery has had conflicting efficacy reported in the existing literature. This study was designed to clarify the usefulness of preemptive local analgesia (PLA) in patients undergoing vaginal hysterectomy. A prospective, randomized, double-blinded trial of PLA in 90 women undergoing vaginal hysterectomy was conducted. PLA consisted of 20 ml of 0.5% bupivacaine with 1:200,000 epinephrine injected in a paracervical-type fashion. Total narcotic use and pain (using a visual analog scale (VAS)) was recorded at 30 min, 3, 12, and 24 h postoperatively. The mean total dose of narcotic was significantly less in the PLA group versus the placebo group (P = 0.009) at every time point postoperatively. Additionally, the mean pain VAS 30 min and 3 h postoperatively was 43% (P = 0.003) and 33% (P = 0.02) lower, respectively, in the PLA group. PLA with bupivacaine prior to vaginal hysterectomy is associated with significantly lower pain scores and a reduction in narcotic use postoperatively.     

Botulinum neurotoxin and other treatments for fissure-in-ano and pelvic floor disorders

BACKGROUND: The management of disorders of the lower gastrointestinal tract, such as chronic anal fissure and pelvic floor dysfunction, has undergone re-evaluation recently. To a large extent this is due to the advent of neurochemical treatments, such as botulinum neurotoxin injections and topical nitrate ointment. METHODS AND RESULTS: This review presents, inter alia, current data on the use of botulinum neurotoxin to treat lower gastrointestinal tract diseases, such as chronic anal fissure for which it promotes healing and symptom relief in up to 70 per cent of cases. This agent has also been used selectively to weaken the external anal sphincter and puborectalis muscle in constipation and in Parkinson's disease. Symptomatic improvement can also be induced in anterior rectocele by botulinum neurotoxin injections. CONCLUSION: Botulinum neurotoxin appears to be a safe therapy for anal fissure. It is more efficacious than nitrate application and does not require patient compliance to complete treatment. While it may also be a promising approach for the treatment of chronic constipation due to pelvic floor dysfunction, further investigation of its efficacy and safety in this role is needed before general usage can be advocated.     

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.     

Joint hypermobility, obstetrical outcomes, and pelvic floor disorders

Introduction and hypothesis

Benign joint hypermobility syndrome may be a risk factor for pelvic floor disorders. It is unknown whether hypermobility impacts the progress of childbirth, a known risk factor for pelvic floor disorders. Our objective was to investigate the association between joint hypermobility syndrome, obstetrical outcomes, and pelvic floor disorders. Our hypotheses were: (1) women with joint hypermobility are less likely to experience operative delivery and prolonged second-stage labor; and (2) pelvic floor disorders are associated with benign hypermobility syndrome, controlling for obstetrical history.

Methods

Joint hypermobility was measured in 587 parous women (participants in a longitudinal cohort study of pelvic floor disorders after childbirth). Their obstetrical histories were obtained from review of hospital records. Pelvic floor disorders were assessed using validated questionnaires and a structured examination for prolapse. Joint hypermobility and pelvic floor disorders were evaluated at enrollment (5–10 years after first delivery). We compared obstetrical outcomes and pelvic floor disorders between women with and without joint hypermobility, defined as a Beighton score ≥4.

Results

Hypermobility was diagnosed in 46 women (7.8 %) and was associated with decreased odds of cesarean after complete cervical dilation or operative vaginal delivery [odds ratio (OR)?=?0.51; 95 % confidence interval (CI):0.27–0.95]. Anal sphincter laceration was unlikely to occur in women with hypermobility (OR?=?0.19; 95 % CI 0.04–0.80). However, hypermobility was not associated with any pelvic floor disorder considered.

Conclusions

Benign joint hypermobility syndrome may facilitate spontaneous vaginal birth but does not appear to be a risk factor for pelvic floor disorders in the first decade after childbirth.     

Prevalence of bowel symptoms in women with pelvic floor disorders

Introduction and hypothesis  

To determine the prevalence of a variety of bowel symptoms in women with pelvic floor disorders     

Magnetic resonance imaging in the diagnosis of pelvic floor disorders

Vaginal prolapse due to pelvic floor dysfunction occurs frequently in postmenopausal women. The disease usually involves all compartments of the vagina, so that isolated defects are uncommon. In advanced disease, it can be difficult to identify which organs are prolapsed, owing to the large bulge in vaginal area. Accurate diagnosis of pelvic floor defects, actual prolapsed organs, and presence of any coexisting abnormalities are essential to correctly plan surgical reconstruction and minimize the risk of recurrence. In this review, we discuss the existing imaging modalities available to evaluate pelvic prolapse, emphasizing the role of dynamic magnetic resonance imaging.     

Pathophysiology of sexual dysfunction as related to pelvic floor disorders

Female sexual dysfunction must be evaluated in the context of age, marital status, and general health status of the woman. Questionnaires evaluating the four domains of female sexual dysfunction can be used as a screening tool to evaluate the effect of pelvic floor disorders and coital leakage, as well as the effect of surgical methods and medical treatment on sexual function. Sexual problems are seldom volunteered symptoms, and only recording whether the woman has dyspareunia and frequency of sexual activity must be considered end-point parameters of a complex function. These parameters cannot explain the pathophysiological causes of the problem. There is a paucity of validated, easily accessible methods and parameters to objectively assess female sexual function.