Suggested Reading

1. Hunt RH. 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 with 12 months' follow up. The Optimal Regimen Cures Helicobacter Induced Dyspepsia (ORCHID) Study Group. BMJ 1999;318:833-837.

Section IV

Anatomic Correlates

Section IV

Anatomic Correlates

G.Willy Davila

A clear and concise understanding of pelvic anatomy is crucial for the management of pelvic floor dysfunction. In the past, the simplistic view that anatomic alterations were primarily responsible for symptomatic dysfunction led to surgical interventions with decreased success rates. Our current concepts intertwine the anatomic and functional aspects of pelvic floor integrity. Therefore, as we evaluate a patient with a clear anatomic defect, emphasis must be placed on what symptomatic, or asymptomatic, dysfunction is present alongside the identified anatomic defect.

Our current concept is one of viewing the pelvic floor as a horizontal unit rather than as a set of vertical compartments.This concept allows us to better understand the interrelationships that occur between organ systems at fascial,muscular,and mucosal levels.A woman with a large posterior vaginal bulge may have a rectocele, an enterocele, both, or neither. A clear knowledge of the rectovaginal septum anatomy will allow the clinician to better evaluate the patient to determine what anatomic alteration is present. Of interest is that clinicians have markedly different terminology for the same anatomic alteration. A clear example of this is the description of a posterior vaginal bulge as a rectocele by gynecologists. Colorectal surgeons tend to view rectoceles with much greater functional emphasis. Understanding anatomic alterations in the rectovaginal septum and clearly describing them is therefore of utmost importance when describing a patient's pelvic floor dysfunction, especially when multiple specialists are involved. The same concept applies to an anterior vaginal bulge. Although cystoceles are common, an anterior vaginal wall bulge can include a larger diverticulum or large inclusion cysts in the urethrovaginal septum, which can occur after a sling procedure. A careful preoperative evaluation is therefore key to determining the etiology of an anatomic alteration.

Physical anatomy must be evaluated and treated within the constraints of neuromuscular integrity. Simply replacing prolapsed organs to their anatomic position will not lead to durable results unless neuromuscular function is improved by postoperative physiotherapy. Optimal results may only be achievable if neurologic integrity is present.

Endofascial layer integrity has been given a significant amount of importance by gynecologic reconstructive surgeons. This concept has not been fully espoused by colorectal surgeons and urologists. Sharing information regarding newly understood anatomic concepts is important when planning a multidisciplinary approach to treatment of pelvic floor dysfunction, especially when surgery is involved.

In this chapter, we have separated the description of pelvic anatomy in a typical compartmentalized format.This is not to de-emphasize our view of the pelvic floor as a horizontal unit. However, to better allow for understanding by the reader, we have opted to present these data in this format.This will undoubtedly lead to some degree of repetition and some variation in the described concepts in pelvic floor anatomy.However,the reader should attempt to place the provided information into a three-dimensional unitary model with underlying common neuromuscular, mucosal, and fascial integrity variables.

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