Available Qualityof Life Assessment Tools

A global assessment tool for pelvic floor dysfunction is not yet available. Although a single tool would be highly desirable, its required complexity may make it impractical. Frequently used global QOL assessment tools, such as the SF-36, do not lend themselves particularly well to pelvic floor dysfunction, because the various aspects of pelvic floor dysfunction are not well covered. Disease-specific QOL questionnaires are required to assess the various parameters involved in pelvic floor...

Sexual Function after Pelvic Surgery

Pelvic surgery to correct prolapse may affect sexual function for a number of reasons including narrowed vaginal canal, poor lubrication, and fear of urinary incontinence. Some studies suggest that sexual dysfunction can occur up to 20 of the time after surgery for prolapse or incontinence. It is thought that the vaginal dissection may lead to pelvic floor neuropathy affecting the pudendal nerve, which subsequently affects vaginal sensation and orgasm. Hysterectomy has been associated with...

Potential Risk Factors

Epidemiologic studies conducted in various populations reveal a number of variables related to the development of UI including several possible risk factors.2 Most studies have found that the prevalence of UI tends to increase with advancing age.3-5 Prevalence has always been higher in institutionalized adults because residents in institutions tend to be older and more impaired than commu nity dwellers. Some studies have found that the proportions of types of UI differ by age. A survey of young...

Session Duration and Frequency

At the onset of biofeedback therapy, it may be difficult to ascertain how many sessions are required for successful training. The number of biofeedback training sessions should be customized for each patient depending on the complexity of their functional disorder as well as the patient's ability to learn and master a new skill. They are typically scheduled from 1 to 1.5 hourly visits once or twice weekly. Additionally, periodic reinforcement is recommended to improve long-term outcome.

Functional Electrical Stimulation

Electrical stimulation has been used for a variety of lower urinary tract symptoms including those of OAB and painful bladder syndrome. There are mainly two types of electrical stimulation chronic, in which low current is used for many hours daily, and acute submaximal functional electrical stimulation, which is applied up to the patient's tolerance for 15 minutes, once or twice a day, three times a week, or daily. The stimulation can be applied transvagi-nally, transrectally, or...

Treatment of Complex Rectovaginal Fistulas

Complex fistulas are high, large, or recurrent and are often secondary to cancer, IBD, or radiation. Consequently, the condition of surrounding tissues (involved with cancer, IBD, scar, or irradiation) may preclude repair with local procedure such as the advancement flap.3 These types of fistulas occur more often in older patients with numerous comorbid conditions, and therefore require more careful preoperative evaluation. In addition,the fistulas themselves require more intense evaluation by...

Anal Sphincter Repair

Fecal continence relies on normal sensory, motor, and reflex activity of the colon, rectum, and anus. Stool consistency, colonic transit, rectal sensation, neural integrity, and sphincter function all have a role in individual control of stool and gas. The principal component in facilitating continence is the anal sphincter, whereas the hemorrhoidal cushions, sensory epithelium of the anal mucosa, intrinsic anorectal reflexes, and pelvic floor muscles contribute to its function. The anal...

Modified McCall Culdoplasty

McCall7 described the technique of surgical correction of enterocele and deep cul-de-sac during vaginal hysterectomy. The McCall culdoplasty closes the redundant cul-de-sac and associated enterocele, provides apical support, and lengthens the vagina. In a randomized study, Cruikshank and Kovac8 demonstrated the superiority of McCall culdoplasty to uterosacral plication and simple peritoneal closure in the prevention of posthysterectomy enterocele. For this reason, we advocate using this...

Treatment of Simple Rectovaginal Fistulas

Simple fistulas may be approached through the vagina, perineum, or rectum. Vaginal approaches are most often used by gynecologists and include the inversion technique and the layered closure. With the patient in the lithotomy position, the inversion technique involves exposure of the fistula by pressure on the rectal side. The vaginal mucosa is incised circumferentially around the fistula. A purses-tring suture is placed in the fistula tract and the needle is passed to the rectal side. Tying of...

Rectoanal Intussusception

Rectoanal intussusception and SRUS have many common features. Dysfunction of the rectum with the development of abnormal defecatory patterns is usually the underlying pathogenesis. Chronic straining may induce intussusception of the rectal mucosa, which in turn may develop into full-thickness rectal prolapse. The occult intussusception may also predispose to a persistent feeling of incomplete evacuation with the chronic urge to strain. Straining may cause excessive tensile forces on the...

The Constipation Scoring System

The clinical presentation of constipation includes a broad spectrum of symptoms, partially attributed to the myriad etiologies. Specifically, constipation may result from slow transit,pelvic outlet obstruction,or other mechanical,phar-macologic, metabolic, endocrine, and neurogenic reasons. Generally, physicians use the term constipation to define infrequent,incomplete,difficult,or prolonged evacuation or to describe stools that are too difficult to pass. However, many patients are more...

Overlapping Sphincter Repair

For most women with fecal incontinence secondary to obstetric trauma, sphincter damage is often occult, persistent, or associated with pudendal nerve damage leading to fecal incontinence many years after delivery. For women with fecal incontinence secondary to a functional yet anatomically disrupted anterior EAS, overlapping sphinc-teroplasty is the operation of choice. This technique is the result of an evolution of a variety of modifications of the initial descriptions of sphincter repair....

Practical Aspects of Biofeedback Therapy for Pelvic Floor Dysfunction

Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems...

Sigmoidoceles

A sigmoidocele, similar to an enterocele, is a true hernia with a break in the fascial supports of the upper vagina-uterosacral-cardinal ligament complex and the rectovagi-nal septum. With increased abdominal pressure, the sigmoid herniates into the cul-de-sac, through the defect, and abuts the vaginal mucosa. This requires a significant redundancy in the sigmoid and a deep cul-de-sac to allow herniation to occur. Sigmoidoceles are believed to cause constipation by obstructing defecation....

Causes of Female Sexual Dysfunction

Similar to its counterpart in the male, there are numerous causes of FSD (Table 5-1.3). In fact, any factors influencing normal physiology, or any step of the sexual response in women, may contribute to FSD. The etiologies can be grouped as being either psychogenic or organic in nature, although overlap often exists. Psychogenic FSD may be noted as either a result of, or a causative factor for, depression. In fact, it behooves the physician to rule out a primary diagnosis of depression in any...

Interstitial Cystitis Painful Bladder Syndrome

Khater Interstitial cystitis (IC) is a chronic, debilitating disease of the urinary bladder characterized by urinary frequency, nocturia, urgency, and frequently pain. It affects more females than males by a ratio of approximately 10 1.' Recently, the International Continence Society has developed a somewhat broader term for IC described as IC-painful bladder syndrome. This new term is defined as the complaint of suprapubic pain related to bladder filling, and is...

Antidepressants and Female Sexual Dysfunction

Although numerous medications can have an adverse impact on sexual function, few classes of medications have been demonstrated to have more impact on sexual function than antidepressants. Although many of the various classes of antidepressant agents can affect sexual function, the selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or fluoxetine, have been shown to adversely affect libido, arousal, as well as the ability to reach orgasm.27 Under a physician's care,...

Colectomy with Ileorectal Anastomosis

Surgical treatment is guided by the results of the specific investigations.3-5 Patients with slow transit constipation, as demonstrated by the failure to eliminate all markers by 7 days during the colonic transit study should be considered for a colectomy and ileorectal anastomosis (IRA). However, this may not be the best option for patients who are unable to evacuate a balloon in the anal physiology laboratory as this may signal rectal dysfunction. Nonetheless, these patients may still be...

Oxybutynin

Oxybutynin is an antimuscarinic agent with pronounced antispasmodic effects and local anesthetic activity, and it has served as the gold standard for treatment of OAB for 3 decades. Several double-blind, controlled studies have demonstrated its efficacy with reports of 50 symptomatic improvement in 61 to 86 of subjects at 15mg daily.4 The original formulation (OXY-IR) is an immediate-release oral administration dosed at 5 mg three to four Table 7-1.1. Available anticholinergic agents for...

Treatment

Women diagnosed with vulvar vestibulitis, particularly at specialty centers, have usually seen multiple clinicians, received numerous courses of medications for infections, and have often been told the problem is psychological. Giving patients a firm diagnosis, reassuring them the problem is real and not in their head, and using the examination to educate them on their genital anatomy can assuage many of their anxieties and increase compliance with recommended therapy. Removing all possible...

Timed Voiding and Fluid Management

Paraiso and George Abate Timed voiding (also referred to as bladder retraining training, bladder drill, bladder discipline, and bladder reeducation) is a behavioral exercise used to establish bladder control in adults. Evidence indicating that bladder training is effective in women with urodynamic urge incontinence with or without associated detrusor overactivity, sensory-urgency without incontinence,1 and urodynamic stress incontinence,2 has led to the 1996 Clinical Practice...

Anorectal Coordination Maneuver for Constipation and Dysfunctional Voiding

The goal is to produce a coordinated movement that consists of increasing intraabdominal (intrarectal) pressure while simultaneously relaxing the pelvic muscles. During the initial sEMG evaluation of the Valsalva maneuver, patients are asked to bear down or strain as if attempting to void or evacuate, which may elicit an immediate pelvic muscle contraction and closure of the anorectal outlet. This correlates with symptoms of constipation including excessive straining and incomplete evacuation....

Risk of Failure and Complications

Clinical conditions that increase the risk of surgical failure for retropubic urethropexy include obesity, menopause, prior hysterectomy, and prior anti-incontinence proce- dures. Advanced age does not seem to be associated with lower rates of cure after colposuspension. Urodynamic findings that increase the risk of surgical failure include signs of intrinsic urethral sphincter deficiency, abnormal perineal electromyography, and concurrent detrusor over-activity. Patients with intrinsic...

Enterourinary Fistula

T.Cristina Sardinha,Samir M.Yebara,and Steven D.Wexner Enterourinary fistulas are usually the result of underlying pathology involving the gastrointestinal or genitourinary tract. Pathologies such as diverticulitis, Crohn's disease, radiation enteritis, trauma, iatrogenic injury, bladder cancer, appendicitis, colon carcinoma, and gynecologic tumors are causes of enterourinary fistulas. The true incidence of enterourinary fistula is unknown, although the most frequent site of fistulization is...

Magnetic Resonance Imaging

The development of fast-scanning magnetic resonance imaging (MRI) techniques has improved our ability to describe and quantify anatomical changes that may cause pelvic floor relaxation. Yang et al.3 were the first to popularize dynamic fast MRI for the evaluation of pelvic organ prolapse. Since then, other investigators have shown that MRI is more sensitive than physical examination for defining pelvic prolapse.4,5 Whereas some advocate the use of contrast opacification of the bladder, vagina,...

Treatment of Urogenital Atrophy

Estrogen replacement therapy is the hallmark of treatment for urogenital atrophy. Because the underlying factor for atrophic changes is a devascularization process, systemic estrogen replacement may not impact the urogenital tissues. This was best described in the recent HERS trial, where stress incontinence symptoms actually worsened on low-dose systemic estrogen replacement therapy.4 Table 11-1.2. Urogynecologic aspects of local estrogen replacement Primary indications Atrophy with urgency,...

Female Sexual Dysfunction and Colorectal Surgery

The occurrence of sexual dysfunction after CRS is a well-recognized phenomenon. Prior studies in men have demonstrated that the incidence of sexual dysfunction is between 20 and 34 in patients undergoing rectal excision, and is related to the extent of the procedure.9 Sexual dysfunction has been attributed to damage of the autonomic nerves, especially during pelvic dissection. Injury to the sympathetic nerves often results in retrograde ejaculation whereas parasympathetic nerve injury can...

Contents

vii ix SECTION I Concept of the Pelvic Floor as a Unit 1-1 Concept of the Pelvic Floor as a Unit SECTION II Epidemiology and Prevalence 2-1 Epidemiology of Non-Neurogenic Urinary Dysfunction Usama M. Khater, Gassan Haddad, and Gamal M. Ghoniem 9 James Doty and Jonathan E. Efron 15 2-3 Genital Prolapse, Urogenital Atrophy, and Sexual Dysfunction Minda Neimark 19 Gamal M. Ghoniem 26 3-1 Primary Evaluation of the Pelvic Floor Nathan Guerette, Dana R. Sands, and G. Willy Davila 27 Gamal M. Ghoniem...

Neurologic Evaluation of the Pelvic Floor

Urinary Frequency

Several elegant methods of neurophysiologic assessment of the anal and urethral sphincters exist. Their purpose is to help localize the site of neurologic pathology leading to the disturbance of bowel and bladder continence and evacuation. Although the clinical neurologic examination may sufficiently determine if the lesion involves the muscle or the nerve control to the muscle, a quantitative assessment of the disturbance by neurophysiologic means is often needed for clinical monitoring and...

Functional Bladder Outlet Obstruction

Functional BOO is a condition, that deserves further attention. Terms such as female aseptic dysuria, female prostatitis, abacterial cystitis, and, most often, the urethral syndrome have been used to describe this condition in the literature.16,17 Such variation in terms reflects both the common symptoms among these patients (recurrent episodes of urinary frequency, urgency, and dysuria without pelvic pain) and the lack of consensus over the etiology and pathophysiology of this condition. Some...

Acupuncture for Pelvic Floor Dysfunction

Acupuncture is an important mainstay of traditional Chinese medicine (TCM). Empirically derived by thousands of years of observation, Chinese medical doctors recorded their treatments almost 2000 years ago in the then modern text, Yellow Emperor's Book of Internal Medicine. Although the physiologic reasoning may seem bizarre to modern allopathic physicians, accepting and understanding the basic tenets does then provide a logical choice of therapy that has withstood the test of time,longer than...

Suggested Reading

Evolving concepts in the pathophysiology of functional gastrointestinal disorder. J Clin Gastroenterol 2002 35(suppl 1) S2-S6. 2. Thumshirn M. Pathophysiology of functional dyspepsia. Gut 2002 51(suppl 1) i63-i66. 3. Talley NJ. Dyspepsia management guidelines for the millennium. Gut 2002 50(suppl IV) iv72-iv78. 4. Talley NJ, Janssens J, Lauritsen K, Racz I, Bolling-Sternevald E. Eradication of Helicobacter pylori in functional dyspepsia randomized double blind placebo controlled trial...

Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD), also referred to as biliary dyskinesia, presents with typical symptoms of biliary colic of right upper quadrant pain with nausea and vomiting. However, this pain is not actually caused by gallstones but instead a motility disorder with spasms of the sphincter of Oddi. By definition, an ultrasound would not show gallstones. In fact, the majority of these patients have already undergone a cholecystectomy, either for gallstones or suspected microlithiasis,...

Dyspepsia

Dyspepsia is derived from the Greek dys and peptein, which literally interpret as bad digestion. The term dyspepsia encompasses a variety of symptoms of persistent upper abdominal pain and discomfort. The predominant symptoms may include pain, heartburn, nausea, early satiety, or postprandial fullness or bloating. This is the most common type of functional upper GI disorder, with a prevalence rate in Western countries estimated at 25 , although less than half will seek medical attention. There...

Bowel Retraining for Anal Incontinence

Anal incontinence is the involuntary loss of control of rectal contents (solid, liquid, or gas) and can be secondary to a variety of causes. Conservative measures such as dietary manipulation, pharmacologic intervention, scheduled rectal emptying, perineal exercises, and biofeedback therapy are effective in many patients who are not surgical candidates or who do not desire surgical intervention for fecal incontinence. The bowel can then be trained to effectively reestablish continence using...

Biofeedback Sessions

At Cleveland Clinic Florida, all patients are requested to keep a 3- to 7-day diary of bladder and bowel habits, laxative, enema, or suppository use, fluid intake, number of home exercises completed, fiber intake, and any associated symptoms of constipation or incontinence. The initial session begins with a history and description of the anatomy and physiology of the bowel, bladder, and pelvic muscle function using anatomic diagrams and visual aids. This is followed by a description of the...

Bowel Retraining for Constipation

The surgeon's first priority when faced with a patient complaining of constipation is to eliminate mechanical obstruction as the cause of the constipation. A complete history and physical examination should be performed. The history needs to focus on multiple factors, but specific attention should be given to the patient's medications as well as their diet and exercise regimen. If mechanical obstruction has not been ruled out before evaluation of the patient, this should be done either by...

Paravaginal Defect Repair

The object of the paravaginal defect repair is to reattach, bilaterally, the anterolateral vaginal sulcus with its overlying endopelvic fascia to the pubococcygeus and obturator internus muscles and fascia at the level of the arcus tendineus fasciae pelvis. The retropubic space is entered and the bladder and vagina are depressed and pulled medially to allow visualization of the lateral retropubic space, including the obturator internus muscle, and the fossa containing the obturator...

Vaginal Devices

Urethral Insertion Tampon

Pessaries have long been used to treat stress urinary incontinence. Standard-shaped pessaries, or those that have been modified with a ball or a protuberance, may successfully treat incontinence. These pessaries stabilize the bladder neck and increase urethral resistance. Vierhout and Lose2 found a 63 subjective cure or improvement rate with pessary use in their review of the literature. A 36 to 66 rate of complete continence has been reported when pessaries were used to treat exercise-induced...

Evacuation Disorders

One of the most common complaints of patients seeing colorectal surgeons is constipation. The prevalence of chronic constipation in the United States varies from 2 to 34 .' Constipation is caused by several etiologies. Pelvic outlet obstruction POO is a common cause of constipation and is attributed to muscular dysfunction of the pelvic floor. The reported incidence of POO as a cause of constipation was reported as high as 50 at a tertiary referral center.2 Population studies have demonstrated...

Obstetric Factors

Obstetric injury is thought to be a principal factor contributing to the development of pelvic floor dysfunction prolapse, urinary and fecal incontinence . This is attributed to direct muscular and connective tissue injury or to denervation injury to the pudendal nerve. There is question as to whether the mode of obstetric delivery, or just the event of being pregnant, has a role in developing prolapse. In a case-control study, patients who delivered their first child before the age of 25 years...