CHAPTER 49 Classification of urogynaecological disorders
Introduction
It is increasingly recognized that colorectal surgeons have an important role in the management of pelvic floor disorders. The studies of Snooks et al (1984a,b) and Sultan et al (1993) show the traumatic effects of vaginal delivery on the pelvic floor and anal sphincters. Wall and de Lancey (1991) succinctly summarized the need for a holistic approach involving gynaecologists, urologists and colorectal surgeons in the management of pelvic floor disorders.
Terminology
Nine reports have now been published, as follows.
Nowadays, the term ‘stress incontinence’ is retained for the symptom of involuntary loss of urine on physical exertion and the sign of urine loss from the urethra immediately on increase in abdominal pressure. The term ‘genuine stress incontinence’ was proposed by the International Continence Society in 1976 (Bates et al 1976) to mean the condition of involuntary loss of urine when ‘the intravesical pressure exceeds the maximum urethral pressure in the absence of a detrusor contraction’. This condition has a number of synonyms: urethral sphincter incompetence, stress urinary incontinence and anatomical stress incontinence. The authors prefer the term ‘urethral sphincter incompetence’ because this accurately describes the pathophysiology of this condition.
In a similar way, the term ‘dyssynergic detrusor dysfunction’ was introduced by Hodgkinson et al in 1963 and other synonyms followed: urge incontinence, uninhibited bladder, bladder instability/unstable bladder and, more recently, overactive bladder. In 1979, the International Continence Society defined an unstable bladder as one ‘shown objectively to contract, spontaneously or on provocation during the filling phase, while the patient is attempting to inhibit micturition. Unstable contractions may be asymptomatic and do not necessarily imply a neurological disorder.’ The contractions are phasic. Another term, ‘low compliance’, is used to mean a gradual increase in detrusor pressure without a subsequent decrease during bladder filling. The term ‘neurogenic detruser overactivity’ is used for phasic uninhibited contractions when there is objective evidence of a relevant neurological disorder. Terms to be avoided include ‘hypertonic’, ‘spastic’ and ‘automatic’.
