Pelvic Floor Dysfunction: A Multidisciplinary Approach PDF
Preview Pelvic Floor Dysfunction: A Multidisciplinary Approach
Pelvic Floor Dysfunction G. Willy Davila, Gamal M. Ghoniem and Steven D. Wexner (Eds.) Pelvic Floor Dysfunction A Multidisciplinary Approach With 178 Figures G.Willy Davila,MD Gamal M.Ghoniem,MD,FACS Chairman,Department Head,Section ofVoiding Dysfunction, ofGynecology;Head,Section Female Urology and Reconstruction ofUrogynecology and Clinical Professor ofSurgery/Urology, Reconstructive Pelvic Surgery NOVA Southeastern University Cleveland Clinic Florida Ohio State University and University of Weston,FL,USA South Florida Affiliate Associate Professor,University Cleveland Clinic Florida ofSouth Florida,USA Weston,FL,USA Steven D.Wexner,MD,FACS,FRCS,FRCSED ChiefofStaff,Cleveland Clinic Hospital 21st Century Oncology Chair in Colorectal Surgery Chairman,Department ofColorectal Surgery Cleveland Clinic Florida Professor ofSurgery,Ohio State University Health Sciences Center at Cleveland Clinic Foundation Clinical Professor ofSurgery,University of South Florida College ofMedicine Research Professor,Charles E.Schmidt College at Florida Atlantic University A Catalogue record for this book is available from the British Library. Library ofCongress Control Number:2005924370 ISBN-10:1-85233-730-3 Printed on acid-free paper ISBN-13:978-1-85233-730-8 © Springer-Verlag London Limited 2006 Apart from any fair dealing for the purposes ofresearch or private study,or criticism or review,as permitted under the Copyright,Designs and Patents Act 1988,this publication may only be reproduced,stored or trans- mitted,in any form or by any means,with the prior permission in writing ofthe publishers,or in the case of reprographic reproduction in accordance with the terms oflicences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.The use ofregistered names,trademarks,etc.in this publication does not imply,even in the absence ofa specific statement,that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability:The publisher can give no guarantee for information about drug dosage and application thereofcontained in this book.In every individual case the respective user must check its accuracy by con- sulting other pharmaceutical literature. Printed in the United States ofAmerica. (BS/MVY) 9 8 7 6 5 4 3 2 1 Springer Science+Business Media springeronline.com I dedicate this work to those who have been instrumental in the development of my urogynecologic career:Dr.Donald Ostergard for teaching me the basics and beyond,Dr. Oscar Contreras Ortiz for encouraging me to become involved,and Dr.Harold Drutz for showing me how to achieve “the balance.”To these mentors and friends I am forever in debt,and no words can express my appreciation for their warmth and interest in my pro- fessional and personal growth.I attempt to emulate their efforts on a daily basis. G.Willy Davila,MD My work on this book is dedicated to the memory ofthe great men who influenced my life’s work,and who passed in December 2003.To the memory of my father,Mostafa Ghoniem and my mentor,Mohamed Al-Ghorab,to whom I will be eternally grateful for their love and support. Gamal Ghoniem,MD This book is dedicated to the most important people in my life – my family. To my parents,for having taught me by their example to succeed by hard work,honesty,and perseverance. Their love and guidance made it possible for me to have achieved my career.To my wife Nicolette,whose devotion to me and to our children and whose intel- lectual stimulation and love have made it possible for me to continue to be productive and innovative.To my children Wesley,Trevor,Marisa,and Gabriella,as it was precious time away from them that allowed me to produce these pages. Steven D.Wexner,MD The editors and authors express their gratitude to Ms.Kristin Dunn and Ms.Stacy Kopka for their exhaustive efforts in preparation of the manuscripts for publication;and Ross Papalardo and Beth Halasz for their superb medical illustration skills. Foreword All the characteristics and driving force of The Cleveland Clinic are to be found in this book on pelvic floor function.The Cleveland Clinic is a group practice founded in 1921 on the principles ofcooperation,collaboration,and collegiality.Its founders believed that many physicians working together will discover better solutions to medical problems than physicians working in isolation.They believed that the combination ofdisciplines, with their inherent differences in philosophy and skills,will produce a better outcome than might have evolved singularly. The power of the collaborative approach is on full display in this book.The pelvic floor unites three separate organ systems.Before this time,each has been approached individually.Urologists,gynecologists,and colorectal surgeons are each trained in their own disciplines,and the pelvic floor is subsumed in these larger fields of study.When they combine their focus on the pelvic floor,they bring their unique perspectives and different approaches to a common goal: the relief of pelvic floor syndromes such as incontinence and pelvic organ prolapse. The notion that three disciplines can combine for a better outcome than they would achieve singly,is a modern-day version ofan old fable.The American poet John Godfrey Saxe (1816–1887) adapted that fable in his poem,“The Blind Men and the Elephant.”It tells the story of six blind wise men who encounter an elephant for the first time,and how they try to make sense ofit by touch alone.The first blind man falls against the side of the elephant,and declares that the elephant is like a wall.The second man feels the tusk and concludes that anything so sharp is like a spear.The third man grabs the trunk and announces that the elephant is like a snake.The fourth man feels the knee and states that the elephant is like a tree.The fifth blind man touches the ear and decides that it is like a fan.The six man grabs the tail and decides it is a like a rope.Each wise man feels the elephant from his own small perspective and visualizes something different.As indi- viduals,they think they have the answer.But if they had combined their impressions, they would have reached a far different conclusion. The practice of joining with colleagues to visualize a problem from your own per- spective and the group perspective,can lead to magnificent conclusions and interesting solutions.That is precisely what happens in this book.By combining the views ofthree different disciplines, which have furthered our knowledge of pelvic floor function, it offers a new and better approach to dysfunction.Medicine has advanced tremendously in the past half century,more specifically in the past two decades.The dominance of traditional specialties such as urology,gynecology,and general surgery has given way to an emphasis on subspecialties such as urogynecology,female urology,and colorectal surgery.This has allowed experts,such as the authors,to focus on a narrower field,and enjoy greater success than they might have if their concentration had been diluted by many broad interests.In this book,they are the personification ofteamwork.Their char- acteristics offocus,innovation,collaboration,and dedication are the very qualities that will someday advance medicine far beyond anything we can imagine today. By combining their expertise in this book, the authors have made a tremendous advance in the understanding of the pelvic floor and its dysfunction.They have raised vii viii Foreword medicine to yet a higher level,and performed a service that will benefit patients with pelvic floor dysfunction for years to come. Robert Kay,MD Vice Chairman,Board ofGovernors ChiefofStaff The Cleveland Clinic Foundation Cleveland OH,USA Introduction The aging of our population and arrival of the baby-boomers to advanced adulthood, with expectations for high quality oflife,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 ofthe aging process.New tech- nologies and a greater understanding of the pathophysiology underlying these dys- functions have provided us with a number of effective tools for treatment of these patients.Unfortunately,the traditional fragmentation of health care duties among spe- cialists 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 cur- ricula to meet the growing need to produce clinicians with an expertise in the manage- ment ofthe various aspects ofpelvic floor dysfunction.Thus,there is not a sole clinician who can care for all ofthe 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 ofacceptance 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 ofthe evaluation and management ofpelvic floor problems exis- tent 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 dys- function 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 ofthe staffat Cleveland Clinic in the management ofdisorders involving the lower urinary,genital,and intestinal tracts.It should be a valuable reference for all cli- nicians 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 similari- ties and analogies in terms of presenting symptoms,evaluation modalities,and treat- ment approaches.It is the hope ofthe authors that clinicians will begin to see the various organ systems as part of a combined unit.As such,recognizing the presence of symp- ix x Introduction 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 oflife and patient satisfaction can be greater when a com- prehensive,horizontally integrated approach is utilized,and we look forward to other centers adopting our model and philosophy of patient care. G.Willy Davila,MD Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii by Robert Kay Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix G.Willy Davila SECTION I Concept of the Pelvic Floor as a Unit 1-1 Concept of the Pelvic Floor as a Unit G.Willy Davila . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 SECTION II Epidemiology and Prevalence 2-1 Epidemiology of Non-Neurogenic Urinary Dysfunction Usama M.Khater,Gassan Haddad,and Gamal M.Ghoniem . . . . . . . . . 9 2-2 Bowel Dysfunction James Doty and Jonathan E.Efron . . . . . . . . . . . . . . . . . . . . . . . . . 15 2-3 Genital Prolapse,Urogenital Atrophy,and Sexual Dysfunction Minda Neimark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 SECTION III Evaluation Introduction Gamal M.Ghoniem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3-1 Primary Evaluation of the Pelvic Floor Nathan Guerette,Dana R.Sands,and G.Willy Davila . . . . . . . . . . . . 27 3-2 Urodynamics Gamal M.Ghoniem and Usama M.Khater . . . . . . . . . . . . . . . . . . . . 35 3-3 Imaging of the Genitourinary Tract in Females M.Louis Moy and Sandip P.Vasavada . . . . . . . . . . . . . . . . . . . . . . . 47 3-4 Anorectal Physiology T.Cristina Sardinha and Dana R.Sands . . . . . . . . . . . . . . . . . . . . . 51 3-5 Anorectal Ultrasound Juan J.Nogueras . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 xi
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