Pelvic floor dysfunction (PFD) is a descriptor of support disorder in which lower urinary tract, lower bowel and genital organs lose their normal support and descend through urogenital hiatus thus leading to uterine prolapse, voiding dysfunction, defecation disorders, pelvic floor hypertonic disorders etc. These problems are usually the consequence of physiological events like pregnancy, childbirth and menopause or diseases affecting gynaecological organs.
It is important to realize that the three organ systems urinary, genital and intestinal traverse the pelvis and exit through their individual orifices and hence these systems are intricately related both anatomically and functionally. These pelvic viscera and orifices are supported by the pelvic floor which is a complex dynamic supportive system.
There is no lesion more distressing than urinary and fecal incontinence. Countless women are bothered by loss of bladder / bowel control, pelvic discomfort and their quality of life has been bleaked by PFD which may be seen in one out of two adult women. Most women never seek care for these socially embarrassing problems and are unaware of the fact that these are amenable to treatment.
A prevalence rate of all PFD combined is not available but estimates of each of these dysfunctions have been reported in epidemiological studies. A study by Henrdrix et al of 16,616 women with a uterus found the rate of uterine prolapse to be 14.2%, the rate of cystocele 34.3% and rate of rectocele 18.6%.1 Another study found that American women have an 11% life time risk of undergoing surgery before the age of 80 for either urinary incontinence or prolapse with 30% of women undergoing repair surgery.2 Urinary incontinence (UI) is a common condition associated with significant burden on the quality of life and economic costs. UI is twice as common in women as in men, with 25 to 45 % of women reporting with some degree of incontinence.3
Fecal / anal incontinence (AI) may have devastating effects on quality of life, self-image and social functioning of all pelvic floor disorders. A multicenter surgery found that 28% of women presenting for routine gynaecologic care reported AI in the preceding year.4 Though our own national statistics regarding PFD are not available but the situation is no different and might even be worse.
The US census bureau projects that by the year 2030, the population over the age of 65 will double to over 70 million in the US, and over one billion worldwide. With increase in aging population, the prevalence of pelvic floor disorders are likely to increase. Over next 30 years, growth in demand for services to treat female pelvic floor disorders will increase at twice the rate of growth of the same population.5 These findings have broad implications for those responsible for administering programs that care for women, allocating research funds in women health and training physicians to meet this escalating demand.
Urogynaecology represents an interface between gynaecologists and urologists. As female pelvic dysfunction comes under the domain of various specialists including urologists, gynaecologists and general surgeons or colo-rected surgeon, so these problems are treated by each one in isolation resulting in multiple surgeries with lot of morbidity and poor outcome. This has been practiced historically which is called as vertical integration. But all structures in the pelvis urinary, genital and alimentary along with musculofacial supports are one functioning unit having common aetiology and pathology in a patient and which we now call horizontal integration. This background has led to the basis of development of urogynaecology as a subspecialty.
In an era of changing practice, including investigations and treatment whether it is medical or surgical we all need to learn as much as possible, as fast as we can and disseminate new knowledge and innovations in treatment. In current economic climate care givers are under pressure to deliver best care with least cost. Now through easy access by television and the internet women are becoming more knowledgeable about different treatment options. This has raised the expectations of our patients and at the same time they have become less tolerant to adverse outcome and complications of treatment. As quoted by Gehart J & Ray Lee, 6 one of the mentors of urogynaecology __ “be an active learner for the rest of your life commit yourself to staying up to date in this fast changing arena”.
During the last four decades there has been considerable progress in the understanding of management of disorders of bladder, lower bowel function and relation of these to prolapse of genital tract. Knowledge is continuously being acquired about the underlying pathologies. Diagnosis is precise and is the basis for rational treatment.
Urogynaecologist is an obstetrician/Gynaecologist who has specialized in the care of women with pelvic floor dysfunction. Urogynaecologic training is achieved through three year fellowship programs in female pelvic medicine and reconstructive surgery under the auspices of both ABOG (American Board of Obstetrician and Gynaecologist) and ABU (American Board of Urologist). Other developed countries have followed the same trend. Through British Society of Urogynaecology and its relationship with Royal College of Obstetrician and Gynaecologist, Urogynaecology has become recognized as a major subspecialty.
Recently College of Physicians and Surgeons Pakistan has started fellowships in different subspecialties of gynaecology and urogynaecology is one of them. At the moment no centre of urogynaecology exists in public sector hospitals in Pakistan. The establishment and promotion of this subspecialty is the need of the hour which will help to provide comprehensive training in pelvic floor disorders in women. To be eligible for consideration as a centre for subspecialty training in urogynaecology, a centre must have an adequate clinical workload of women with wide range of urogynaecological problems and with facilities for their investigations. In addition these centres should be in close link with other related specialities such as urology, neurology, care of elderly, colorectal surgery and physiotherapy. By establishing such centres patients with these problems can be dealt with at one place, thereby patient care is improved, educational opportunities are enhanced and collaborative research is encouraged. Trainees in these centres are needed to meet future clinical, research and educational demands. The urogynaecologist is best optimized to implement evidence based and well planned approaches to evaluate and treat women with these common disorders.
- Hendrix SL, Clark, et al. Pelvic prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186:1160-1166.
- Oslen AL, Smith VJ, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89-501-506.
- Nazeema Y, Siddiqui Pamela J, et al. Perception about female urinary incontinence: a systematic review. Int Urogynecol J 2014; 25:863-871.
- Boreham MK, Richter HE, et al. Anal incontinence in women presenting for gynaecologic care. Am J Obstet Gynecol 2005; 192:1637-1642.
- Wu JM, Hundley AF, Fulton RG, Myers ER Forecasting the prevalence of pelvic floor disorders in US women: 2010 to 2050. Obstet Gynecol 2009;114:1278-1283.
- Gehart J, Ray Lee, 1931-2012: surgeon, teacher, mentor, friend. Int Urogynecol J 2013;24(8):1257.