Video Clips on DVD
- 8-1
Examination of a Patient with a Large Rectocele and Rectal Prolapse
- 8-2
Laparoscopic Sacrocolporectopexy
Historically, the pelvic floor has been segmented into three separate and distinct compartments with the urologist managing the anterior compartment, the gynecologist managing the vaginal compartment, and the colorectal specialist managing the posterior compartment. Only recently have we begun to appreciate the tremendous overlap of symptoms with which these patients present.
As the female population ages, pelvic floor disorders will become increasingly prevalent. It is estimated that over the next 40 years, the number of women with at least one pelvic floor symptom will nearly double from 28 million to 48 million. The number of women with overactive bladder (OAB) and urinary incontinence (UI) will increase at least 55%, women with fecal incontinence will increase by 59%, and those with pelvic organ prolapse will increase by 46%.
Data from the National Health and Nutrition Examination Survey (NHANES) estimate that 24% of all adult women will eventually have symptoms of pelvic floor dysfunction in at least one compartment. As baby boomers age and numbers of women living beyond the age of 65 increases, there will be an enormous need for skilled clinicians to address these multicompartmental defects both by conservative and surgical therapies.
Patients with pelvic floor dysfunction can potentially present with a multitude of symptoms that may include lack of bladder or bowel control, loss of pelvic support, a variety of pain disorders, and difficulty with evacuation of urine or stool. Functionality of the pelvic floor relies on multiple anatomic supports from muscles, ligaments, and bones, as well as an intrinsic nerve supply. For this reason, it is common that one defect will coexist with others and that a multidisciplinary approach can result in a more complete evaluation and management plan.
Miedel et al. in 2008, reported on a cohort of 206 women who were evaluated to assess associations between compartmental prolapse and pelvic floor symptoms. Compartmental defects in the anterior, posterior, and apical support were quantified in conjunction with complaints of bowel, urinary, or mechanical symptoms (bulge and/or pressure). Not surprisingly, there was a wide overlap in reports of bowel and urinary symptoms with 63% of women reporting either urge or stress incontinence and 73% of women complaining of at least one bowel symptom (hard stool, difficult evacuation, pain). Incontinence of flatus was reported in 40% of women. Incontinence of both stool and urine coexisted in up to 60% of women complaining of either symptom. Mechanical symptoms of bulge were frequently associated with multiple compartmental prolapses, whereas the posterior vaginal wall was the most common area with an isolated defect. Interestingly, they also reported an association between stress incontinence and isolated prolapse of the posterior compartment.
There has also been significant literature showing that women who present with bowel or urinary complaints will commonly have pelvic organ prolapse, which may or may not be symptomatic.
The complex nature of pelvic floor disorders and tremendous overlap of symptoms from multiple compartments often requires a multidisciplinary approach to the evaluation and management of pelvic floor dysfunction ( Fig. 8-1 ). Frequently, this involves cooperation and collaboration between colorectal specialists, urogynecologist, urologists, and physical therapists. At times, collaboration with other specialists such as plastic surgery, gastroenterology, and neurology may also be required. Figures 8-2 and 8-3 elaborate on the various functional and anatomic abnormalities that a practitioner can encounter.
Cases with Complex Pelvic Floor Symptoms Requiring a Multidisciplinary Approach
Case 1
An 84-year-old, para 5, female patient presented to the office from her assisted-living facility after being diagnosed with a urinary tract infection that required in-house IV antibiotics 2 weeks ago. On evaluation in the emergency department before her admission, it was noted that she had significant prolapse of the rectum, uterus, vagina, and urethra ( Fig. 8-4 ) . In addition, the nursing facility reported that the patient has had blood on her underwear on occasion over the last few months. Her medical history is complicated by chronic obstructive pulmonary disease (COPD) and a myocardial infarction (MI) in the past as well as mild dementia. She denied any urinary incontinence but admitted to frequent incontinence of flatus and occasional stool.
