- Email: [email protected]
Multidisciplinary management of pelvic floor disorders
Seminars in Colon and Rectal Surgery 27 (2016) 1–4
Contents lists available at ScienceDirect
Seminars in Colon and Rectal Surgery journal homepage: www.elsevier.com/locate/yscrs
Multidisciplinary management of pelvic floor disorders Andrea Kakos, MDa, Mickey Karram, MDb,c,d, Ian Paquette, MDd,e,n a
The Christ Hospital/The University of Cincinnati, Cincinnati, OH Department of Obstetrics & Gynecology, University of Cincinnati, Cincinnati, OH Department of Urology, University of Cincinnati, Cincinnati, OH d Center For Pelvic Floor Disorders, Christ Hospital, Cincinnati, OH e Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Ave 524, Cincinnati, OH b c
a b s t r a c t Pelvic floor disorders are being diagnosed in women with increasing frequency. Disorders of the different compartments of the pelvic floor (anterior, middle, and posterior) often occur simultaneously. A multidisciplinary approach is often needed to pursue the proper workup and reach the optimal treatment regimen. Pelvic floor centers are emerging as a model in which to treat these complex patients. Lastly, we will highlight case examples of how a pelvic floor center can be beneficial to the workup and management of these patients. & 2016 Elsevier Inc. All rights reserved.
Introduction The pelvic floor can be thought of as three distinct components. In its simplest form, the anterior compartment includes the urethra and bladder; the vaginal compartment includes the cervix, vagina, and uterus; and the posterior compartment, includes the anus and rectum.1 The current practice for treating disorders of the pelvic floor is evolving from a segmented, single compartment model, into a multidisciplinary approach, appreciating the pelvic floor as a multi compartment dynamic system. The collaborative expertise of urologists, gynecologists, colorectal surgeons, gastroenterologists, and physical therapists is often required to treat these complex disorders. Patients with pelvic floor disorders can present with a wide range of symptoms including anatomic and functional complaints. Anatomical derangements of each compartment of the pelvic floor may present in isolation, or in combination to abnormalities of the other compartments of the pelvic floor (Table). Functional derangement can include lower urinary tract symptoms, including disorders of storage or evacuation; defecatory dysfunction, including incontinence or outlet obstruction; or pain disorders, including dyspareunia. Simple screening tools can help identify patients with these disorders, who may not otherwise feel comfortable bring up these sensitive issues to a medical provider. One such screening tool is the Pelvic Floor Distress Inventory (PFDI), or PFDI20 short form. The PFDI is made up of the Pelvic Organ Prolapse
n
Corresponding author at: Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Ave 524, Cincinnati, OH. E-mail address: [email protected] (I. Paquette). http://dx.doi.org/10.1053/j.scrs.2015.12.001 1043-1489/& 2016 Elsevier Inc. All rights reserved.
Distress Inventory 6 (POPDI-6), Colorectal–Anal Distress Inventory (CRAD-8), and the Urinary Distress Inventory 6 (UDI-6).2–6 The prevalence of pelvic floor disorders, including urinary incontinence, fecal incontinence and pelvic organ prolapse, has been shown to affect nearly 25% of women based upon the National Health and Nutrition Examination Survey.7,8 The most common pelvic floor disorder is urinary incontinence with a prevalence of 16%, followed by fecal incontinence at 9% and pelvic organ prolapse at 3%. However, a recent Cochrane review reported the prevalence of fecal incontinence to range from 2% to 17%9 these results come from clinical studies with differing definitions, and may underestimate the true prevalence of this condition. A large survey of woman 4 45-year old in the United States revealed that 15.6% of women of ages 45–54 years had at least one episode of accidental bowel leakage per year, while 23.1% of women over age 75 experience this problem at least once per year.10 With the aging of the population, the prevalence of pelvic floor disorders will certainly increase over time. One recent estimate is that by the year 2050, 58.2 million women in the United States will have at least one pelvic floor disorder.11 It is important to recognize these trends and to educate both patients and providers of all specialties of the prevalence of these disorders and their treatment options, as one study on fecal incontinence indicated that less than onethird of incontinent patients surveyed have ever discussed these symptoms with a doctor, and in those who did, about 50% chose to discuss these symptoms with only their primary care doctor.12
Symptom overlap It is important to recognize that pelvic floor disorders do not always occur in isolation and that a high degree of symptom
2
A. Kakos et al. / Seminars in Colon and Rectal Surgery 27 (2016) 1–4
Table Anatomic pelvic floor abnormalities. Anterior compartment Urethral prolapse Cystocele Middle compartment Anterior or posterior vaginal prolapse Enterocele Uterovaginal prolapse Posterior compartment Anal sphincter disruption Rectal prolapse Rectal intussusception Rectocele Sigmoidocele
overlap exists. A study of 113 consecutive patients treated in a multidisciplinary pelvic floor center noted two main patterns of clustering of symptoms: first, the association with rectoceles and obstructed defecation, and second, the presentation with mixed fecal and urinary incontinence.13 Bano and Barrington14 surveyed 200 women presenting for gynecological exams, they found a high prevalence of constipation, fecal incontinence and defeacatory disorders in these women. Furthermore, Kahn and Stanton15 showed that some symptoms such as constipation, incomplete bowel emptying, and fecal incontinence, do not always resolve following posterior colporrhaphy, and that symptoms may worsen or occur de novo. Again, these studies highlight the burden and overlap between pelvic floor disorders and the dynamic pelvic floor model.
Evaluation Evaluation of these disorders can be extensive and requires special equipment and expertise.16,17 Detailed history and physical exams are imperative and should precede any special testing. Histories should include the duration, symptoms, and an wobjective quantification severity. A typical physical exam for female pelvic floor disorders may include evaluation of the urethra, vulva, vagina, and cervix, bimanual exam of uterus and adnexa, and rectal exam. When vaginal prolapse is noted, it is often defined using the pelvic organ prolapse quantification exam (POP-Q) as a way to standardize the exam findings.1 Using these findings, a compartment and stage is assigned corresponding to the most significant prolapse. In addition to history and physical exam, cystoscopic evaluation, urodynamic bladder testing,18,19 anoscopy, and/or endoanal ultrasound,20,21 anorectal physiology testing,20,22–24 or defecography25 may also be indicated.
The value of a pelvic floor center A pelvic floor clinic or center (PFC) can facilitate the multispecialty care of these complex patients.13 The ideal pelvic floor center has the expertise of multiple types of specialists, including urology, urogynecology, colorectal surgery, and physical therapy. With these resources, patients with simple, isolated problems are easily managed, and more complex patients with mixed pelvic floor disorders are directed into the appropriate diagnostic workup and multidisciplinary management. Ideally, a pelvic floor center should have the resources to perform a detailed physical examination (lighting, scopes, specula, commode, etc.) and
diagnostic capabilities such as cystoscopy, urodynamics, ultrasound, manometry testing, and defecography. With these resources in place, patients may quicky go through the often lengthy diagnostic process, and be offered the appropriate course of management in an expeditious manner. Streamlining the process of diagnosis and multidisciplinary management has the potential to improve patient satisfaction, an increasingly important metric, as it will be tied to reimbursement in the future.26 Kapoor et al.13 reviewed 113 cases treated over 3 years in their pelvic floor center. They found that the PFC lead to a more pragmatic treatment approach, combined surgery was undertaken in one quarter of their patients, and these cases were associated with cost savings and single recuperation period with high patient satisfaction. It is important to note that though pelvic floor centers are generally profitable entities, not all centers have the resources to build a freestanding pelvic floor center. In these instances, many hospitals have developed the model of a virtual pelvic floor center, in which physicians dedicated to treating these disorders collaborate to develop care pathways for the multidisciplinary diagnosis and management of pelvic floor disorders. Regardless of which model of pelvic floor center is used, a patient navigator can be an essential component to enhance the patient experience. A navigator can sort though the initial patient triage process to determine which diagnostic modalities to pursue, and which specialists a patient should be seen by. This is particularly important in the realm of overactive bladder and fecal incontinence, where many patients are treated in a stepwise approach with conservative measures prior to considering interventional treatments. In an audit of our own practice, we noted that 4 50% of overactive bladder patients seen for an initial visit and prescribed a first line medication never returned for a subsequent visit. Additionally, of patients who were prescribed a medication for overactive bladder, only 2–3% ultimately went on to receive third line therapy (Botox injection, percutaneous tibial nerve stimulation, or sacral neuromodulation) due to lack of followup in our system. A patient navigator has the ability to follow patients throughout their entire care pathway and help assure that a higher proportion of patients receive the appropriate medical treatment for their pelvic floor disorder, resulting in a higher patient satisfaction. To illustrate the types of patients who are often managed using a multidisciplinary approach, we will highlight the cases of two recent patients in our pelvic floor center.
Case 1 A 70-year-old woman presented with symptoms of difficulty with evacuation of stool. She felt the sensation of pressure and an urge to have a bowel movement, but had an inability to pass stool unless she used manual pressure on the posterior vaginal wall. She also noted the presence of a visual bulge of the posterior vagina. Colonoscopy ruled out a colorectal malignancy. She denied any urinary symptoms. Physical examination revealed normal sphincter tone, but suggested a paradoxic contraction of the puborectalis muscle. A moderately large rectocele was present. Anorectal physiology testing revealed normal resting and squeeze pressures. The rectoanal inhibitory reflex was present. Though the patient could expel the balloon upon request, EMG testing did suggest nonrelaxation of the puborectalis muscle. Defecography revealed a 5-cm rectocele with poor emptying unless manual pressure was used (Fig.). There was also as suggestion of nonrelaxation of the puborectalis muscle. There was no evidence of enterocele, sigmoidocele, or vaginal vault prolapse.
A. Kakos et al. / Seminars in Colon and Rectal Surgery 27 (2016) 1–4
3
defect,27 she elected to undergo a stage 1 trial implantation of SNM. At the end of the trial period, she had significant improvement in her FI, with a Cleveland Clinic Florida score of 3, and her bladder diary indicated 450% improvement in OAB episodes. She subsequently had a full system SNM implantation and is very satisfied with the results of both her fecal and urinary function. To summarize, there are a significant number of women affected by pelvic floor disorders. These disorders are a consequence of a dynamic pelvic floor system. The multidisciplinary pelvic floor center is an emerging model, in which a comprehensive diagnosis and treatment plan may be facilitated in a multidisciplinary setting to restore optimal pelvic floor function and patient satisfaction.
References
Fig. Static image from defecography noting a moderately large anterior rectocele.
In addition to optimizing her medical bowel regimen, she was referred for biofeedback treatment, and was compliant with this regimen. Although she noted some improvement in her ability to initiate a bowel movement, she continued to require manual vaginal splinting to complete a bowel movement. After a multidisciplinary discussion, she underwent a transvaginal rectocele repair by urogynecology. She recovered uneventfully from the procedure, and expressed significant improvement in her ability to complete a bowel movement without the assistance of manual pressure.
Case 2 A 60-year-old neurologically intact female initially presented with a chief complaint of urinary frequency, urgency, and multiple bouts of urge incontinence per day. Prior to presentation, she had been tried on two different antmuscarinic drugs, which failed to improve her condition. She was prescribed a B3 agonist (Mirabegron) as well as instructed on behavioral modification in the form of timed voiding and given instructions on how to appropriately utilize her pelvic floor muscles. In follow-up visit 6 weeks later, no significant improvement was noted in her condition. A voiding diary revealed very little change in symptoms. Cystourethroscopy was performed to rule any bladder or urethral pathology and multichannel urodynamics documented the presence of multiple uninhibited bladder contractions during filling cystometry. During this visit, she also endorsed worsening fecal incontinence as well. Her history was notable for two vaginal deliveries, and fecal incontinence for the past 5 years. Her Cleveland Clinic Florida incontinence score was 15/20. Anorectal manometry revealed diminished resting pressures in the anal canal, most pronounced anteriorly. A 3D transrectal ultrasound revealed a 1201 disruption of the external anal sphincter. She was treated with a bowel regimen to optimize stool consistency and a home regimen of Kegel exercises, but continued to experience refractory fecal incontinence and overactive bladder. A multidisciplinary discussion was held and based upon the presence of both FI and OAB, as well as recent evidence, that sacral neuromodulation (SNM) appears to be effective, despite the presence of a sphincter
1. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17. 2. Barber MD, Chen Z, Lukacz E, et al. Further validation of the short form versions of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). Neurourol Urodyn. 2011;30:541–546. 3. Chan SS, Cheung RY, Lai BP, Lee LL, Choy KW, Chung TK. Responsiveness of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire in women undergoing treatment for pelvic floor disorders. Int Urogynecol J. 2013;24:213–221. 4. Gafni-Kane A, Zhou Y, Botros SM. Predictive modeling and threshold scores for care seeking among women with urinary incontinence: the short forms of the Pelvic Floor Distress Inventory and Urogenital Distress Inventory. Neurourol Urodyn. 2015. 5. Letouzey V, Mercier G, Adjoussou S, Bohoussou E, Mares P, de Tayrac R. Can the PFDI (Pelvic Floor Distress Inventory) or PFIQ (Pelvic Floor Impact Questionnaires) be used to predict outcome in pelvic reconstructive surgery? Prog Urol. 2013;23:940–945. 6. Utomo E, Blok BF, Steensma AB, Korfage IJ. Validation of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) in a Dutch population. Int Urogynecol J. 2014;25:531–544. 7. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. J Am Med Assoc. 2008;300:1311–1316. 8. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123:141–148. 9. Brown S, Wadhawan H, Nelson R. Surgery for fecal incontinence in adults. Cochrane Database Syst Rev. 2013. 10. Brown HW, Wexner SD, Segall MM, Brezoczky KL, Lukacz ES. Accidental bowel leakage in the mature women's health study: prevalence and predictors. Int J Clin Pract. 2012;66:1101–1108. 11. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol. 2009;114: 1278–1283. 12. Brown HW, Wexner SD, Segall MM, Brezoczky KL, Lukacz ES. Quality of life impact in women with accidental bowel leakage. Int J Clin Pract. 2012;66: 1109–1116. 13. Kapoor DS, Sultan AH, Thakar R, Abulafi MA, Swift RI, Ness W. Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic. Colorectal Dis. 2008;10:118–123. 14. Bano F, Barrington JW. Prevalence of anorectal dysfunction in women attending health care services. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:57–60. 15. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol. 1997;104:82–86. 16. Steele SR, Varma MG, Prichard D, et al. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg. 2015;52:92–136. 17. Steele SR, Varma MG, Prichard D, et al. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg. 2015;52:17–75. 18. Serati M, Giarenis I, Meschia M, Cardozo L. Role of urodynamics before prolapse surgery. Int Urogynecol J. 2015;26:165–168. 19. Chester J, Toozs-Hobson P, Israfil-Bayli F. The role of ambulatory urodynamics in investigation of female urinary incontinence. Int Urogynecol J. 2015. 20. Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American society of colon and rectal surgeons' clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623–636. 21. Santoro GA, Wieczorek AP, Shobeiri SA, et al. Interobserver and interdisciplinary reproducibility of 3D endovaginal ultrasound assessment of pelvic floor anatomy. Int Urogynecol J. 2011;22:53–59. 22. Liberman H, Faria J, Ternent CA, Blatchford GJ, Christensen MA, Thorson AG. A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence. Dis Colon Rectum. 2001;44:1567–1574.
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23. Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of any value? Int J Colorectal Dis. 2010;25:277–282. 24. Quezada Y, Whiteside JL, Rice T, Karram M, Rafferty JF, Paquette IM. Does preoperative anal physiology testing or ultrasonography predict clinical outcome with sacral neuromodulation for fecal incontinence? Int Urogynecol J. 2015;26:1613–1617.
25. Mellgren A, Bremmer S, Johansson C, et al. Defecography. Results of investigations in 2,816 patients. Dis Colon Rectum. 1994;37:1133–1141. 26. Healthcare.gov. Vol. 2015; 2015. 27. Johnson BL 3rd, Abodeely A, Ferguson MA, Davis R, Rafferty JF, Paquette IM. Is sacral neuromodulation here to stay? Clinical outcomes of a new treatment for fecal incontinence. [discussion 19–20]. J Gastrointest Surg. 2015;19:15–19.
Contents lists available at ScienceDirect
Seminars in Colon and Rectal Surgery journal homepage: www.elsevier.com/locate/yscrs
Multidisciplinary management of pelvic floor disorders Andrea Kakos, MDa, Mickey Karram, MDb,c,d, Ian Paquette, MDd,e,n a
The Christ Hospital/The University of Cincinnati, Cincinnati, OH Department of Obstetrics & Gynecology, University of Cincinnati, Cincinnati, OH Department of Urology, University of Cincinnati, Cincinnati, OH d Center For Pelvic Floor Disorders, Christ Hospital, Cincinnati, OH e Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Ave 524, Cincinnati, OH b c
a b s t r a c t Pelvic floor disorders are being diagnosed in women with increasing frequency. Disorders of the different compartments of the pelvic floor (anterior, middle, and posterior) often occur simultaneously. A multidisciplinary approach is often needed to pursue the proper workup and reach the optimal treatment regimen. Pelvic floor centers are emerging as a model in which to treat these complex patients. Lastly, we will highlight case examples of how a pelvic floor center can be beneficial to the workup and management of these patients. & 2016 Elsevier Inc. All rights reserved.
Introduction The pelvic floor can be thought of as three distinct components. In its simplest form, the anterior compartment includes the urethra and bladder; the vaginal compartment includes the cervix, vagina, and uterus; and the posterior compartment, includes the anus and rectum.1 The current practice for treating disorders of the pelvic floor is evolving from a segmented, single compartment model, into a multidisciplinary approach, appreciating the pelvic floor as a multi compartment dynamic system. The collaborative expertise of urologists, gynecologists, colorectal surgeons, gastroenterologists, and physical therapists is often required to treat these complex disorders. Patients with pelvic floor disorders can present with a wide range of symptoms including anatomic and functional complaints. Anatomical derangements of each compartment of the pelvic floor may present in isolation, or in combination to abnormalities of the other compartments of the pelvic floor (Table). Functional derangement can include lower urinary tract symptoms, including disorders of storage or evacuation; defecatory dysfunction, including incontinence or outlet obstruction; or pain disorders, including dyspareunia. Simple screening tools can help identify patients with these disorders, who may not otherwise feel comfortable bring up these sensitive issues to a medical provider. One such screening tool is the Pelvic Floor Distress Inventory (PFDI), or PFDI20 short form. The PFDI is made up of the Pelvic Organ Prolapse
n
Corresponding author at: Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Ave 524, Cincinnati, OH. E-mail address: [email protected] (I. Paquette). http://dx.doi.org/10.1053/j.scrs.2015.12.001 1043-1489/& 2016 Elsevier Inc. All rights reserved.
Distress Inventory 6 (POPDI-6), Colorectal–Anal Distress Inventory (CRAD-8), and the Urinary Distress Inventory 6 (UDI-6).2–6 The prevalence of pelvic floor disorders, including urinary incontinence, fecal incontinence and pelvic organ prolapse, has been shown to affect nearly 25% of women based upon the National Health and Nutrition Examination Survey.7,8 The most common pelvic floor disorder is urinary incontinence with a prevalence of 16%, followed by fecal incontinence at 9% and pelvic organ prolapse at 3%. However, a recent Cochrane review reported the prevalence of fecal incontinence to range from 2% to 17%9 these results come from clinical studies with differing definitions, and may underestimate the true prevalence of this condition. A large survey of woman 4 45-year old in the United States revealed that 15.6% of women of ages 45–54 years had at least one episode of accidental bowel leakage per year, while 23.1% of women over age 75 experience this problem at least once per year.10 With the aging of the population, the prevalence of pelvic floor disorders will certainly increase over time. One recent estimate is that by the year 2050, 58.2 million women in the United States will have at least one pelvic floor disorder.11 It is important to recognize these trends and to educate both patients and providers of all specialties of the prevalence of these disorders and their treatment options, as one study on fecal incontinence indicated that less than onethird of incontinent patients surveyed have ever discussed these symptoms with a doctor, and in those who did, about 50% chose to discuss these symptoms with only their primary care doctor.12
Symptom overlap It is important to recognize that pelvic floor disorders do not always occur in isolation and that a high degree of symptom
2
A. Kakos et al. / Seminars in Colon and Rectal Surgery 27 (2016) 1–4
Table Anatomic pelvic floor abnormalities. Anterior compartment Urethral prolapse Cystocele Middle compartment Anterior or posterior vaginal prolapse Enterocele Uterovaginal prolapse Posterior compartment Anal sphincter disruption Rectal prolapse Rectal intussusception Rectocele Sigmoidocele
overlap exists. A study of 113 consecutive patients treated in a multidisciplinary pelvic floor center noted two main patterns of clustering of symptoms: first, the association with rectoceles and obstructed defecation, and second, the presentation with mixed fecal and urinary incontinence.13 Bano and Barrington14 surveyed 200 women presenting for gynecological exams, they found a high prevalence of constipation, fecal incontinence and defeacatory disorders in these women. Furthermore, Kahn and Stanton15 showed that some symptoms such as constipation, incomplete bowel emptying, and fecal incontinence, do not always resolve following posterior colporrhaphy, and that symptoms may worsen or occur de novo. Again, these studies highlight the burden and overlap between pelvic floor disorders and the dynamic pelvic floor model.
Evaluation Evaluation of these disorders can be extensive and requires special equipment and expertise.16,17 Detailed history and physical exams are imperative and should precede any special testing. Histories should include the duration, symptoms, and an wobjective quantification severity. A typical physical exam for female pelvic floor disorders may include evaluation of the urethra, vulva, vagina, and cervix, bimanual exam of uterus and adnexa, and rectal exam. When vaginal prolapse is noted, it is often defined using the pelvic organ prolapse quantification exam (POP-Q) as a way to standardize the exam findings.1 Using these findings, a compartment and stage is assigned corresponding to the most significant prolapse. In addition to history and physical exam, cystoscopic evaluation, urodynamic bladder testing,18,19 anoscopy, and/or endoanal ultrasound,20,21 anorectal physiology testing,20,22–24 or defecography25 may also be indicated.
The value of a pelvic floor center A pelvic floor clinic or center (PFC) can facilitate the multispecialty care of these complex patients.13 The ideal pelvic floor center has the expertise of multiple types of specialists, including urology, urogynecology, colorectal surgery, and physical therapy. With these resources, patients with simple, isolated problems are easily managed, and more complex patients with mixed pelvic floor disorders are directed into the appropriate diagnostic workup and multidisciplinary management. Ideally, a pelvic floor center should have the resources to perform a detailed physical examination (lighting, scopes, specula, commode, etc.) and
diagnostic capabilities such as cystoscopy, urodynamics, ultrasound, manometry testing, and defecography. With these resources in place, patients may quicky go through the often lengthy diagnostic process, and be offered the appropriate course of management in an expeditious manner. Streamlining the process of diagnosis and multidisciplinary management has the potential to improve patient satisfaction, an increasingly important metric, as it will be tied to reimbursement in the future.26 Kapoor et al.13 reviewed 113 cases treated over 3 years in their pelvic floor center. They found that the PFC lead to a more pragmatic treatment approach, combined surgery was undertaken in one quarter of their patients, and these cases were associated with cost savings and single recuperation period with high patient satisfaction. It is important to note that though pelvic floor centers are generally profitable entities, not all centers have the resources to build a freestanding pelvic floor center. In these instances, many hospitals have developed the model of a virtual pelvic floor center, in which physicians dedicated to treating these disorders collaborate to develop care pathways for the multidisciplinary diagnosis and management of pelvic floor disorders. Regardless of which model of pelvic floor center is used, a patient navigator can be an essential component to enhance the patient experience. A navigator can sort though the initial patient triage process to determine which diagnostic modalities to pursue, and which specialists a patient should be seen by. This is particularly important in the realm of overactive bladder and fecal incontinence, where many patients are treated in a stepwise approach with conservative measures prior to considering interventional treatments. In an audit of our own practice, we noted that 4 50% of overactive bladder patients seen for an initial visit and prescribed a first line medication never returned for a subsequent visit. Additionally, of patients who were prescribed a medication for overactive bladder, only 2–3% ultimately went on to receive third line therapy (Botox injection, percutaneous tibial nerve stimulation, or sacral neuromodulation) due to lack of followup in our system. A patient navigator has the ability to follow patients throughout their entire care pathway and help assure that a higher proportion of patients receive the appropriate medical treatment for their pelvic floor disorder, resulting in a higher patient satisfaction. To illustrate the types of patients who are often managed using a multidisciplinary approach, we will highlight the cases of two recent patients in our pelvic floor center.
Case 1 A 70-year-old woman presented with symptoms of difficulty with evacuation of stool. She felt the sensation of pressure and an urge to have a bowel movement, but had an inability to pass stool unless she used manual pressure on the posterior vaginal wall. She also noted the presence of a visual bulge of the posterior vagina. Colonoscopy ruled out a colorectal malignancy. She denied any urinary symptoms. Physical examination revealed normal sphincter tone, but suggested a paradoxic contraction of the puborectalis muscle. A moderately large rectocele was present. Anorectal physiology testing revealed normal resting and squeeze pressures. The rectoanal inhibitory reflex was present. Though the patient could expel the balloon upon request, EMG testing did suggest nonrelaxation of the puborectalis muscle. Defecography revealed a 5-cm rectocele with poor emptying unless manual pressure was used (Fig.). There was also as suggestion of nonrelaxation of the puborectalis muscle. There was no evidence of enterocele, sigmoidocele, or vaginal vault prolapse.
A. Kakos et al. / Seminars in Colon and Rectal Surgery 27 (2016) 1–4
3
defect,27 she elected to undergo a stage 1 trial implantation of SNM. At the end of the trial period, she had significant improvement in her FI, with a Cleveland Clinic Florida score of 3, and her bladder diary indicated 450% improvement in OAB episodes. She subsequently had a full system SNM implantation and is very satisfied with the results of both her fecal and urinary function. To summarize, there are a significant number of women affected by pelvic floor disorders. These disorders are a consequence of a dynamic pelvic floor system. The multidisciplinary pelvic floor center is an emerging model, in which a comprehensive diagnosis and treatment plan may be facilitated in a multidisciplinary setting to restore optimal pelvic floor function and patient satisfaction.
References
Fig. Static image from defecography noting a moderately large anterior rectocele.
In addition to optimizing her medical bowel regimen, she was referred for biofeedback treatment, and was compliant with this regimen. Although she noted some improvement in her ability to initiate a bowel movement, she continued to require manual vaginal splinting to complete a bowel movement. After a multidisciplinary discussion, she underwent a transvaginal rectocele repair by urogynecology. She recovered uneventfully from the procedure, and expressed significant improvement in her ability to complete a bowel movement without the assistance of manual pressure.
Case 2 A 60-year-old neurologically intact female initially presented with a chief complaint of urinary frequency, urgency, and multiple bouts of urge incontinence per day. Prior to presentation, she had been tried on two different antmuscarinic drugs, which failed to improve her condition. She was prescribed a B3 agonist (Mirabegron) as well as instructed on behavioral modification in the form of timed voiding and given instructions on how to appropriately utilize her pelvic floor muscles. In follow-up visit 6 weeks later, no significant improvement was noted in her condition. A voiding diary revealed very little change in symptoms. Cystourethroscopy was performed to rule any bladder or urethral pathology and multichannel urodynamics documented the presence of multiple uninhibited bladder contractions during filling cystometry. During this visit, she also endorsed worsening fecal incontinence as well. Her history was notable for two vaginal deliveries, and fecal incontinence for the past 5 years. Her Cleveland Clinic Florida incontinence score was 15/20. Anorectal manometry revealed diminished resting pressures in the anal canal, most pronounced anteriorly. A 3D transrectal ultrasound revealed a 1201 disruption of the external anal sphincter. She was treated with a bowel regimen to optimize stool consistency and a home regimen of Kegel exercises, but continued to experience refractory fecal incontinence and overactive bladder. A multidisciplinary discussion was held and based upon the presence of both FI and OAB, as well as recent evidence, that sacral neuromodulation (SNM) appears to be effective, despite the presence of a sphincter
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