Introduction

The aging of our population and arrival of the baby-boomers to advanced adulthood, with expectations for high quality of life, have led to a greater public awareness and help-seeking behavior regarding symptomatic dysfunction of the organs found within the pelvic cavity in women, the female pelvic floor. Women are increasingly less willing to simply accept incontinence or prolapse as a normal part of the aging process. New technologies and a greater understanding of the pathophysiology underlying these dysfunctions have provided us with a number of effective tools for treatment of these patients. Unfortunately, the traditional fragmentation of health care duties among specialists has led to significant gaps in the treatment of pelvic floor dysfunction. The concept of the female pelvic floor as a single functional unit has not yet gained wide acceptance. Importantly, postgraduate training programs have not adapted their curricula to meet the growing need to produce clinicians with an expertise in the management of the various aspects of pelvic floor dysfunction. Thus, there is not a sole clinician who can care for all of the problems that can develop within the pelvic floor. Under our current medical care environment, a multidisciplinary team approach will best serve the needs of symptomatic women. The need for such a team is gaining increasing degrees of acceptance at referral centers. Unfortunately, multiple barriers are in place to prevent such teams from forming and functioning efficiently.

There are currently efforts around the world to delineate training requirements for certification in Urogynecology/Female Pelvic Medicine/Reconstructive Pelvic Surgery (after training in Obstetrics and Gynecology) and Female Urology (after training in Urology). Colorectal surgeons and gastroenterologists have long had an interest in anatomic and functional problems of the lower intestinal tract. Nevertheless, clinicians caring for adjacent pelvic organ systems have yet to achieve a consensus regarding the importance and value of the evaluation and management of pelvic floor problems existent on either side of an anatomic system. As a result, patients may undergo sequential operative procedures and/or achieve only limited quality-of-life improvement with therapy.

Realizing the above shortcomings and the frequent coexistence of pelvic floor dysfunction symptoms among many patients referred for care, the Cleveland Clinic, at its various campuses, has developed a team approach to the care of such patients. Either within one Pelvic Floor Center, such as at our Fort Lauderdale/Weston, Florida campus or in very close proximity, such as in our Naples, Florida or Cleveland, Ohio campuses, patients are evaluated and treated by a team of clinicians with expertise in the various aspects of symptomatic dysfunction. After coordination of evaluation procedures, a treatment plan is designed. Whether care involves a combined surgical procedure or medical intervention, a patient's medical care is streamlined and patients benefit from a global quality-of-life improvement. This text represents a compilation of the clinical approaches of the staff at Cleveland Clinic in the management of disorders involving the lower urinary, genital, and intestinal tracts. It should be a valuable reference for all clinicians involved in the care of women with symptomatic dysfunction of these systems. It will be apparent to clinicians from various fields that there are remarkable similarities and analogies in terms of presenting symptoms, evaluation modalities, and treatment approaches. It is the hope of the authors that clinicians will begin to see the various organ systems as part of a combined unit. As such, recognizing the presence of symp toms involving adjacent organ systems will encourage clinicians to recruit and involve other clinicians with expertise in addressing such symptoms in order to optimize the medical care being provided to a symptomatic patient. Our experience has demonstrated that improvements in quality of life and patient satisfaction can be greater when a comprehensive, horizontally integrated approach is utilized, and we look forward to other centers adopting our model and philosophy of patient care.

G. Willy Davila, MD

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