Pelvic Floor Dysfunction : a Multidisciplinary Approach

342 Pages·2009·12.425 MB·English

by  Davila, G. Willy, Ghoniem, Gamal M., Wexner, Steven D

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
ISBN978-1-84800-347-7 e-ISBN978-1-84628-010-8
DOI 10.1007/978-1-84628-010-8
© Springer-Verlag London Limited 2008
First published 2006 in hardcover as ISBN 978-1-85233-730-8
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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
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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-
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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