Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction

The reported prevalence rates of pain within the pelvis range from 3.8% to 24% in women aged 15 to 73 years. Despite the significant number of women affected, pelvic floor pain and dysfunction are commonly overlooked in women seeking medical care. Physiatrists are uniquely qualified to manage these patients because of their knowledge of the musculoskeletal and nervous systems and their awareness of the relationships among pain, physiology, and function. When evaluating women who have pelvic pain, practitioners must ask questions about history of urinary or fecal incontinence, dyspareunia, or pelvic pain with certain activities or associated with menses, surgery, or trauma. If left unidentified, pelvic floor dysfunction can deter individuals from normal bowel and bladder function, intimacy, and even engagement in work and social functions. This article introduces pelvic floor anatomy, neurophysiology, and function and provides an overview of pelvic pain and pelvic floor dysfunctions and their recognition and treatment.

Seeking healthcare for pelvic floor disorders: a population-based study

OBJECTIVE

The purpose of this study was to identify characteristics that are associated with seeking care for pelvic floor disorders (PFD).

STUDY DESIGN

Strategies for seeking care for pelvic organ prolapse, urinary incontinence (UI), and anal incontinence (AI) were assessed in 4392 women. Women were dichotomized into women who had sought care and women with disorders who had not. Chi-square and t tests were used to compare demographic and medical variables. Logistic regression was used to calculate adjusted odds ratios (ORs) with 95% CI.

RESULTS

Women who sought care were significantly older (64 +/- 13.1 vs 55 +/- 14.8 years old; P < .001). After an adjustment for significant variables, care-seeking was associated with increasing age per year (prolapse OR, 1.07 [95% CI, 1.04-1.11]; UI OR, 1.04 [95% CI, 1.02-1.05]), hysterectomy (prolapse OR, 4.30 [95% CI, 2.16-8.55]; UI OR, 1.40 [95% CI, 1.05-1.89]), hormone replacement (UI OR, 1.78 [95% CI, 1.29-2.45]), and urinary infections (AI OR, 1.67 [95% CI, 1.04-2.68]).

CONCLUSION

Seeking care for PFD is associated with older age, hysterectomy, hormone use, and frequent urinary tract infection. This reinforces the need for PFD treatment as our population ages and demand increases.

[Medical treatment for female pelvic floor dysfunction and prospective role of urologists]

With declining birthrate and graying of population, the significance of female pelvic floor dysfunction (FPFD) and importance of its medical treatment are being emphasized in developed nations. In our country, more and more urological departments have started working on FPFD in the past several years. Compared to the past times when only gynecologists treated pelvic organ prolapse, now pelvic support problems and its inherent lower urinary tract dysfunction are treated simultaneously in a better way by urologists' participation. The urological approach has added compound eyes to pelvic relaxation disorders. Further effort is expected to help develop novel technology in the treatment of stress urinary incontinence. Although it is certain that female pelvic floor medicine is beneficial to our society, its possibility and limitation remain to be studied.

[Symposium 3 "female urology in the future"]

Symposium 3 entitled "Female Urology in the Future" is very timely as female urology, a urological subspecialty mainly managing stress urinary incontinence (SUI), pelvic organ prolapse (POP) and overactive bladder (OAB), is now beginning to blossom in Japan. In 1986, the first Japanese female incontinence clinic was opened at the Department of Urology, Nagoya University. In 1999, the tension-free vaginal tape (TVT) procedure using polypropylene mesh tape to support the mid-urethra was introduced into Japan, and it dramatically changed the SUI treatment with less era"). invasiveness and durability ("mesh Recently, a variation of the TVT procedure, transobuturator tape (TOT) procedure, and POP repair using polypropylene mesh such as tension-free vaginal mesh (TVM) procedure, are the focus of concern among Japanese urologists and gynecologists practicing female pelvic floor medicine. The International Continence Society derived a new symptomatic definition of overactive bladder (OAB) in 2002. The Neurogenic Bladder Society in Japan published the OAB guideline aiming at public education and shared care in 2005. Five symposists discuss the advantages and pitfalls of the new mesh procedures for SUI and POP, conservation of the uterus in POP repair, gender specificity of OAB, basic research to develop OAB drugs other than anticholinergics, collaboration between urologists and gynecologists, and pediatric female urology.

[Present state of female urology]

This chapter critically reviews the literature on surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP), and medical treatment for overactive bladder in women. The midurethral polypropylene sling was reported to provide a durable option with significant improvement. The tension-free vaginal tape (TVT) procedure is based on a theory of pathophysiology of stress incontinence presented by Petros and Ulmsten. In their "integral theory" impairment of the pubourethral ligament is one of the primary cause of SUI. The transobturator sling was found to be effective in SUI patients with less incidence of perioperative complications and voiding difficulties. Prolapse of the uterus/vaginal apex and posterior vaginal wall may also be found in women with stress incontinence. There are many procedures for the correction of POP. Transvaginal repair of anterior and posterior compartment prolapse with polypropylene mesh has been developed in recent years. It is necessary to assess and compare the current quality of outcomes.

Patient-selected goals: the fourth dimension in assessment of pelvic floor disorders

The purpose of the study was to assess the relationship between self-expressed urogynecologic goals, symptoms, and treatment choice. Charts of women presenting for urogynecology consultation were reviewed. Demographics, diagnoses and responses to the pelvic floor distress inventory and medical, social, and epidemiologic aspects of aging questionnaires were recorded. Patients listed urogynecology goals before consultation. We categorized goals into five categories and then compared these categories by symptom type, severity, and treatment. Three hundred five women reported 635 goals (median 2, range 1-6). The number of goals listed per patient did not differ by age, race, comorbidities, or clinical diagnosis (p > 0.05). The most frequent goal category was symptoms (67%), followed by information seeking (12%), lifestyle (11%), emotional (4%), and "other" (6%). Women selecting non-surgical treatment were more likely to list information seeking as primary goal than those who chose surgery (p = 0.009). One third of participants expressed a primary non-symptom goal and were more likely to seek non-surgical therapy.

Uterine prolapse complicating pregnancy

BACKGROUND

Uterine prolapse is extremely rare during pregnancy. However in some cases significant complications may develop. We report a case of uterine prolapse which developed during pregnancy. Our case was managed conservatively and there were no fetal or maternal complications. Postnatally the uterine prolapse recovered spontaneously. Early recognition and close follow-up during pregnancy is essential. Successful pregnancy outcome requires individualized treatment but bed rest should always be considered.

Vesicovaginal fistula resulting from a well-cared-for pessary

An 84-year-old vaginally grand multiparous woman presented with a vesicovaginal fistula (VVF) after appropriate use of a Gehrung pessary for the past 12 years for stage III pelvic organ prolapse. The patient reported strict adherence to removing her pessary nightly and replacing it in the morning for the last 12 years. One morning, she awoke and noted a sudden gush of urine through the vagina followed by continuous leakage. Given the complex nature of VVF repair with concurrent stage III pelvic organ prolapse, the patient was referred to urogynecologic care. A Latzko fistula repair and LeFort colpocleisis were performed without complication. The patient recovered well with complete resolution of her pelvic organ prolapse and VVF based on negative cystogram findings at 3 weeks postoperatively. At 12 weeks postoperatively the patient denied any urine leakage or pelvic organ prolapse.

The Colpexin Sphere: a new conservative management option for pelvic organ prolapse

Pelvic organ prolapse is a frequently overlooked condition occurring commonly among women of all ages. A brief overview of pelvic organ prolapse and a discussion of the Colpexin Sphere is provided. The Colpexin Sphere is a new intravaginal device that facilitates the performance of pelvic floor muscle exercises thereby enhancing the benefit provided by already established conservative therapy.

Presentation of a device used by elderly women with prolapse in eastern part of Turkey

OBJECTIVE

Presentation of a device used by three elderly women with prolapse in eastern part of Turkey.

METHOD

Information about device is obtained by face to face interview technique. Microbiologic examination of the device and vaginal cultures were performed.

RESULTS

Three women with genital polapse using an ancient device were found incidentally and information about device, their knowledge about genital prolapse, and solutions were obtained.

CONCLUSION

By the help of related media and women health organizations the women especially who live in rural area should be educated about reproductive health care and if necessary health policies revisions should be considered.

Conservative management of pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse is common, and some degree of prolapse is seen in 50% of parous women. Women with prolapse can experience a variety of pelvic floor symptoms. Treatments include surgery, mechanical devices and conservative management. Conservative management approaches, such as giving lifestyle advice and delivering pelvic floor muscle training, are often used in cases of mild to moderate prolapse.

OBJECTIVES

To determine the effects of conservative management (physical interventions and lifestyle interventions) for women with pelvic organ prolapse in comparison with no treatment or other treatment options (such as mechanical devices or surgery).

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched on 19 September 2005), MEDLINE (January 1966 to August 2005), MEDLINE In Process & Other Citations (15 September 2005), EMBASE (January 1996 to Week 43 2005), CINAHL (January 1982 to October 2005), PEDro (September 2005), the UK National Research Register (Issue 3, 2005), the US National Institute of Health clinical trial register (5 October 2005), Current Controlled Trials register (5 October 2005), Controlled Clinical Trials (September 2005) and ZETOC (September 2005). We searched the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials in women with pelvic organ prolapse that included a physical or lifestyle intervention in at least one arm of the trial.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed all trials for inclusion/exclusion and methodological quality. Data were extracted by the lead reviewer onto a standard form and cross checked by another. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three trials of relevance to this review were identified. The largest of these, of pelvic floor muscle training in preventing anterior prolapse from worsening, had significant limitations which affect the generalisability and rigor of the findings. A small feasibility study (which is to be followed up with a larger trial) randomised 47 women to pelvic floor muscle training or control and found suggestions of better outcomes (better self-reported improvement, decreased severity) in the intervention group. The third trial evaluated peri-operative physiotherapy for women undergoing surgery for prolapse and/or incontinence. The authors report that urinary symptoms, pelvic floor muscle function and quality of life were improved more in the treatment group than the control group, but data were not provided to allow this to be assessed. The trial was small and no prolapse-specific outcome measures were used. It was not possible to combine data from the three trials.

AUTHORS' CONCLUSIONS

Despite there now being reports of three eligible trials in this update, the evidence available is not significant to guide practice. There is some encouragement from a feasibility study that pelvic floor muscle training, delivered by a physiotherapist to symptomatic women in an outpatient setting, may reduce severity of prolapse. Further evidence from larger, better quality randomised control trials is however still necessary.

Optimizing pelvic organ prolapse research

For many years, researchers on this field have suffered from the lack of an efficient method for describing pelvic organ prolapse. Struggling to solve this problem, the International Continence Society has proposed a pelvic organ prolapse quantification (POP-Q) system [Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, Shull B, Smith ARB, Am J Obstet Gynecol, 175(1):1956-1962, 1996], which was validated as a precise and reproducible technique for describing pelvic organ position. However, even though very precise at describing pelvic organ position, our critic to this system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four grades, almost the same way as Baden and Walker did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this paper is to propose a method that makes POP research more efficient by directly measuring prolapse as a continuous variable that requires lesser number of subjects in order to achieve statistical significance.

Surgical Innovations in Pelvic Organ Prolapse and Incontinence

Pelvic organ prolapse (POP) and urinary incontinence (UI) are common problems facing the geriatric woman. Many patients may find great benefit from medical or conservative treatments; however, surgical options are commonly used in many cases. This article examines the current medical and surgical innovations for POP and UI that have the potential to improve the patient's quality of life.

Forgotten vaginal pessary eroding into rectum

Vaginal pessaries still have a role in the management of uterine prolapse, particularly in elderly patients. However, they are known to cause serious complications if proper care is not taken. We present a case of a rectovaginal fistula, developing secondary to a forgotten vaginal pessary. The shelf pessary was found to have eroded through into the rectum. A review of the relevant literature was undertaken and complications associated with vaginal pessaries are discussed.

Effect of Vaginal Pessaries on Symptoms Associated With Pelvic Organ Prolapse

OBJECTIVE

To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure.

METHODS

All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months.

RESULTS

Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71-12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction.

CONCLUSION

A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy.

LEVEL OF EVIDENCE

II-3.

Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse

OBJECTIVE

This study was undertaken to evaluate the responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women with pelvic organ prolapse undergoing surgical and nonsurgical management.

STUDY DESIGN

The responsiveness of the prolapse, urinary and colorectal scales of the PFDI and PFIQ were assessed in 2 independent populations: (1) 42 women with stage II or greater prolapse enrolled in an ongoing multicenter randomized trial comparing 2 different pessaries (Pessary group) and (2) 64 women with stage III or greater prolapse who underwent vaginal reconstructive surgery (Surgery group). All subjects completed the PFDI and PFIQ at baseline and again either 3 months (Pessary group) or 6 months (Surgery group) after initiation of treatment. Responsiveness was assessed with standardized response mean (SRM), effect size (ES), and the paired t test.

RESULTS

In the Pessary group, there was a significant improvement in the prolapse and urinary scales of the PFDI, with each demonstrating moderate responsiveness (prolapse: SRM 0.69, ES 0.68; urinary: SRM 0.57, ES: 0.50, P < .001 for each). The colorectal scale of the PFDI and each of the 3 scales of the PFIQ demonstrated no significant change in scores with pessary use. In the Surgery group, there was a significant improvement in the prolapse, urinary, and colorectal scales of both the PFDI and PFIQ (P < .01 for each). The prolapse and urinary scales of the PFDI demonstrated excellent responsiveness with SRM and ES 1.20 or greater for the prolapse scale and equal to1.05 for the urinary scales. The colorectal scale of the PFDI and the urinary and prolapse scales of the PFIQ demonstrated moderate responsiveness (SRM 0.61-0.70 and ES 0.56-0.60) after surgery. Subjects who had a recurrence of their prolapse develop after surgery (6%) had significantly less improvement in the prolapse scale of the PFDI than those who did not. After controlling for preoperative prolapse stage and baseline quality of life scores, subjects in the Surgery group had significantly greater improvement in each of the scales of the PFDI and the prolapse and urinary scales of the PFIQ than did the Pessary group (P < .05 for each).

CONCLUSION

The PFDI and PFIQ are responsive to change in women undergoing surgical and nonsurgical treatment for pelvic organ prolapse. The PFDI is more responsive than the PFIQ.

[Efficacy and safety of Pelvicol in the vaginal treatment of prolapse]

OBJECTIVES

To evaluate the efficacy and safety of a porcine biomaterial (Pelvicol) in the transvaginal surgical treatment of urogenital prolapse.

MATERIAL AND METHOD

Prospective study from June 2001 to February 2004 based on 132 patients with a mean age of 67.6 +/- 9.89 years presenting major urogenital prolapse: 132 cystoceles and 84 rectoceles with 100% and 63.4% of grade 2 or 3, respectively. Patients were evaluated by questionnaire and clinical examination at 1 month, 6 months, 12 months and 24 months after the operation. Two hundred and sixteen Pelvicol implants were inserted via a vaginal approach: 132 anterior implants and 84 posterior implants.

RESULTS

The mean follow-up was 21 months [range: 6-24]. No intraoperative complication was observed. The postoperative complication rate was 11.3% (15/132) including 1 prosthetic exposure with a favourable outcome. After 6 months, 1 recurrence of cystoceles and 1 recurrence of rectoceles were found in 132 patients. Out of the 117 patients followed up for 12 months, 6 presented with grade 2 cystoceles and 1 grade 2 rectoceles. After 24 months, out of the 107 patients evaluated, 18 cystoceles and 9 rectoceles of grade 2 or 3 were found. Globally, 83.1% of patients did not present with grade 2 or 3 recurrences after 24 months. Safety was considered to be good with 10% of moderate pelvic pain and 6% of de novo dyspareunia at 12 months. The overall satisfaction rate was 94%.

CONCLUSION

These preliminary results demonstrate an efficacy of 83.1% at 24 months and the good safety of Pelvicol in the transvaginal surgical treatment of urogenital prolapse.

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience

OBJECTIVE

To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS).

PATIENTS AND METHODS

UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS).

RESULTS

Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack.

CONCLUSION

Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.