The clinical problems of pelvic organ prolapse and incontinence that affect women due to their unique role in reproduction have helped define the field of obstetrics and gynecology over the last 150 years. The recent identification of female pelvic medicine/reconstructive surgery as an area of subspecialization within obstetrics and gynecology recognizes the growing strength of this discipline. A total of 37 accredited fellowship programs exist at leading academic institutions and membership in specialty-associated societies has more than doubled in the last 15 years. Research support from the National Institutes of Health and foundations has led to exciting basic and translational research as well as well-designed and well-conducted multicenter randomized clinical trials. Continued efforts should allow this field to establish the same national infrastructure present in the other long-established subspecialties.
Women suffering from pelvic organ prolapse and incontinence have been recorded since the earliest medical writings. Clear descriptions of prolapse are found in the Kahun papyrus (1835bce) “Of a women whose posterior belly and branching of her thighs are painful, say thou it is the falling of the womb.” (Kahun papyrus, Column 1, Griffiths translation.) During the 19th and early 20th century, gynecology emerged as the specialty focused on addressing these common and distressing problems. This article summarizes the current status of efforts to advance treatment and prevention for pelvic floor disorders and places these efforts into historical context.
The field of obstetrics and gynecology arose primarily from the need to address women’s unique role in reproduction. Although some surgical gynecologists such as Howard Kelly aligned themselves with general surgery in the early part of this century, the close relationship between vaginal birth and pelvic floor disorders led to the current posture of our specialty that manages birth and the resultant pelvic floor injuries. In the era where opening the peritoneal cavity often resulted in sepsis and death, transvaginal operations provided a degree of safety that allowed surgeons to develop techniques for operative repair of prolapse and incontinence. Beginning with repair of vesicovaginal fistulae, the field of gynecologic surgery was firmly rooted in repair of pelvic floor disorders. Treatment of these conditions was seen as a core element of obstetrics and gynecology.
In the late 1970s, subspecialization was officially recognized within obstetrics and gynecology. It was judged that additional training was needed in gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology and infertility beyond the typical training received during general obstetrics and gynecology residencies and these subspecialties were recognized by the American Board of Obstetrics and Gynecology (ABOG). With the additional training and academic focus brought by this recognition, great strides were made. Management of pelvic floor disorders was considered “what all gynecologists do” and this specialty was not considered for subspecialization. In the years that followed there was also a growing focus on primary care for women. Pelvic floor surgery became a smaller and smaller part of the typical obstetrics and gynecology practice and research in the field was limited.
Continued interest in pelvic floor disorders and a growing appreciation that improved clinical and research training would be needed to put care for women with pelvic floor disorders on par with the other subspecialty areas of academic and clinical interest led to efforts at subspecialization. Fellowship training had started at a number of institutions and consideration of seeking recognition and accreditation was begun. Because of the mutual interest of obstetricians, gynecologists, and urologists in pelvic floor problems, discussions were held between ABOG and American Board of Urology (ABU) resulting in the establishment of fellowship accreditation in female pelvic medicine/reconstructive surgery (FPM/RS). Although there is a clear need for further advance subspecialty training in these areas, routine care for the many patients with uncomplicated pelvic floor disorders will continue to be provided by generalist obstetrician gynecologists. This broad effort will be needed in view of the projected 45% growth in demand over 30 years. Further work will be needed to clarify how many subspecialists are needed and whether the current complement of training programs is sufficient.
Establishment of FPM/RS training program accreditation
The FPM/RS Board consists of 3 gynecologists and 3 urologists with the executive directors of ABOG and ABU serving in an ex officio capacity. This arrangement of equal representation between gynecology and urology was well suited to the mutual interest in these problems and has been a remarkably collegial collaboration. In the first phase of fellowship development there were approximately 25 programs that achieved accreditation. These programs were led by existing pioneers within the field, most of whom were self-trained or who had gathered additional experience through extended visits to specialty units. The number of programs stayed static for a number of years until individuals who had received training in the newly accredited programs reached a stage in their career when they would start their own programs. The current complement of programs stands at 37 with continued new applications arriving each year. An indication of the breadth of this training is shown in the Table that summarizes the table of contents for the ABOG guide to learning in FPM/RS.
| I. Anatomy |
| II. Physiology and pelvic floor including normal lower urinary tract, colo-rectal-anal and vaginal function |
| III. Pathophysiology of urinary and anal incontinence and pelvic organ prolapse |
| a. Urinary incontinence |
| b. Fecal incontinence |
| c. Pelvic organ prolapse and pelvic floor dysfunction |
| IV. Treatment of urinary incontinence (excluding fistula and diverticulum) |
| a. Surgical treatment |
| b. Pharmacological treatment |
| c. Behavioral treatment |
| d. Functional treatment |
| V. Treatment of fecal incontinence |
| VI. Pelvic floor dysfunction and prolapse–nonsurgical and surgical management |
| VII. Vesicovaginal, urethrovaginal fistula and diverticulum of urethra |
| VIII. Rectovaginal fistula |
| IX. Intraoperative injury–prevention and immediate management |
| X. Congenital anomalies of female genital tract |
| XI. Irritative conditions of genitourinary tract |
| a. Urinary tract infections |
| b. Sensory disorders of bladder and urethra |
| c. Interstitial cystitis |
| d. Urethral syndrome |
| e. Sensory urgency and frequency syndrome |
| f. Nonurologic irritative conditions of pelvis |
| XII. Neurogenic bladder |
| XIII. Statistics |
| XIV. Research and thesis |
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