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Drusany Starič K, Distefano REC, Campo G, Norčič G. Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned. Front Surg 2023; 10:1260355. [PMID: 37693638 PMCID: PMC10483572 DOI: 10.3389/fsurg.2023.1260355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
Background Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being. Case A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent. Conclusions This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.
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Affiliation(s)
- Kristina Drusany Starič
- Division of Gynaecology and Obstetrics, Department of Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Rosario Emanuele Carlo Distefano
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Giorgia Campo
- Division of General Surgery and Medical Surgical Specialties, Department of Obstetrical and Gynecological Pathology, University of Catania, Catania, Italy
| | - Gregor Norčič
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Hainsworth A, Ferrari L, Malde S, Berry L. Building a Multidisciplinary Pelvic Floor Clinic: Why Bother? SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic. Female Pelvic Med Reconstr Surg 2021; 27:e505-e509. [PMID: 32371720 DOI: 10.1097/spv.0000000000000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability. METHODS This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits. RESULTS The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed. CONCLUSIONS A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.
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Yoo R, Spencer M. Continence Promotion and Successful Aging: The Role of the Multidisciplinary Continence Clinic. Geriatrics (Basel) 2018; 3:geriatrics3040091. [PMID: 31011126 PMCID: PMC6371153 DOI: 10.3390/geriatrics3040091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 11/16/2022] Open
Abstract
Incontinence is a common yet under-recognized issue that impacts quality of life, especially for older adults in whom there is often a multifactorial etiology. A retrospective chart review was performed on a representative sample of patients seen at our multidisciplinary continence clinic in Vancouver, Canada from January to December 2017 inclusive. Initial assessment was performed by the nurse continence advisor (NCA) or geriatrician depending on the source of referral. The pelvic floor physiotherapist (PFP) could then be consulted based on perceived need. The average age at assessment was 76 years old (range 29⁻102), with 82% of patients ≥65 years and 27% ≥85 years old. The majority of patients were referred for bladder incontinence (72%), with the remaining patients referred for bowel incontinence (28%) or pessary care (7%). Referrals came from a variety of sources including physicians (62%), nurses (22%), allied health care providers (12%) and self-referral (5%). Multimorbidity was common, with 40% of patients having a Charlson Comorbidity Index ≥6. The same proportion of patients (40%) were on ≥5 prescription medications. Many patients were functionally dependent for either instrumental activities of daily living (52%) or activities of daily living (25%). Non-pharmacologic treatments were commonly recommended, with the majority of patients counselled on lifestyle changes (88%) and taught Kegel exercises (70%). For patients seen by the geriatrician, modifications were made to non-continence medications in 50% of cases and medical comorbidities were optimized in 39% of cases. In terms of pharmacologic therapy, over-the-counter (OTC) medications were initiated in 45% of patients whereas continence-specific prescription medications were started in 17% of patients. A multidisciplinary continence clinic can play an important role in promoting successful aging by assessing and treating medical causes of incontinence in medically complex older adults.
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Affiliation(s)
- Rhena Yoo
- MD Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.
| | - Martha Spencer
- Division of Geriatric Medicine, Providence Health Care, Vancouver, BC, V6Z 1Y6, Canada.
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Classic papers on pelvic floor physiotherapy: the most frequently cited articles in three decades (1983-2013). Int Urogynecol J 2018; 29:1429-1433. [PMID: 29442142 DOI: 10.1007/s00192-018-3573-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor physiotherapy has been utilized extensively over the past decades for the treatment of pelvic floor dysfunctions. The aim of this study was to identify and characterize the most frequently cited articles on pelvic floor physiotherapy published in the last 30 years. METHODS A PubMed search of all articles published between 1983 and 2013 was performed. Articles with more than 100 citations were identified as "classic," and were further analyzed based on author names, year of publication, journal of publication, subject, study design, country of research, and number of citations. In 2017, a new search for papers on pelvic floor physiotherapy was conducted using the same methods to compare them with the 2013 data. RESULTS Of 1,285 articles published between 1983 and 2013, only 20 articles were cited more than 100 times. Among them, we found 12 randomized clinical trials (RCTs) and only 4 reviews. The most common topics among the classic articles were behavior therapy, pelvic floor muscle training (PFMT), biofeedback-assisted PFMT, and neuromuscular electrical stimulation. In 2017, we found 1,745 papers containing the term "pelvic floor physiotherapy," indicating an increase of around 35% in 4 years. CONCLUSIONS Although there is a fast-growing number of publications, we still have few classic papers on pelvic floor physiotherapy, concentrated in a few research centers. However, the large number of RCTs shows that these papers have a high scientific level, confirming that they can be classified as classic papers.
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Al-Mozany N, Wright C, O'Grady G, Young CJ, Solomon MJ. Barriers to the management of obstructed defaecation according to colorectal surgeons. Colorectal Dis 2017; 19:649-655. [PMID: 28319316 DOI: 10.1111/codi.13665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 10/17/2016] [Indexed: 12/13/2022]
Abstract
AIM Obstructed defaecation (OD) has a high prevalence and high disease impact; however, patients often experience suboptimal management. This problem reflects the complex pathophysiology of OD as well as health service delivery factors. This study aimed to identify the factors that act as a barrier to effective management of OD as perceived by specialist colorectal surgeons treating this disorder. METHOD A postal questionnaire was administered to a bi-national sampling of colorectal specialists in Australia and New Zealand who were registered with their specialty society. Questions addressed variables relevant in OD management, including clinical access, decision-making, patient factors and surgeon experience and perceptions, and used Likert scales. Statistical analyses compared surgeon practice variables. RESULTS The response rate was 68.5% (n = 113). Most surgeons managed OD (94%), and preferred to treat OD patients themselves (87%); however, 33% of these respondents were dissatisfied with their management, 46% felt they lacked management expertise and 33% stated they had inadequate expertise in OD investigations. Clinical investigation services were more limited in private than public practice, and many surgeons lacked access to biofeedback (31%). Other barriers included heterogeneity in decision-making by surgeon age and practice location (P < 0.05), dual pathologies (e.g. irritable bowel syndrome) and psychological factors, and limited uptake of multidisciplinary services and standardized (Rome) diagnostic criteria. CONCLUSION Barriers to OD management include surgeon-specific factors, patient-specific factors and healthcare access factors. Increased utilization of pelvic floor and multidisciplinary services, increased training and standardization of OD investigations and improved access to specialist investigations and allied-health management services could improve outcomes for OD.
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Affiliation(s)
- N Al-Mozany
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand
| | - C Wright
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - C J Young
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand
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Hainsworth AJ, Schizas AMP, Brown S, Williams AB. The future of pelvic floor services in the UK. Colorectal Dis 2016; 18:1087-1093. [PMID: 27027907 DOI: 10.1111/codi.13341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/03/2016] [Indexed: 01/03/2023]
Abstract
AIM The study aimed to determine the current state of UK pelvic floor services and to discuss future strategies. METHOD A questionnaire developed by the Pelvic Floor Society was sent in 2014 to the 175 colorectal units recognized by the Association of Coloproctology of Great Britain and Ireland. Questions included type of centre, frequency of pelvic floor clinics/interdisciplinary joint pelvic floor clinics/multidisciplinary meetings (MDMs) and workload. RESULTS Sixty-seven (38%) centres replied including 75% of units with a consultant who was as member of the Pelvic Floor Society. Of the 67 centres 39% were tertiary centres for pelvic floor surgery (tertiary), 48% performed some pelvic floor surgery (regional) and 13% did not perform any (local). Ninety-six per cent of tertiary referral centres served a population over 500 000. The mean number of whole time equivalent consultants in tertiary centres was 1.03 and 0.77 in regional centres. Eighty per cent of tertiary centres and 56% of regional centres ran pelvic floor clinics. Eighty-four per cent of tertiary referral and 75% of regional units held or attended an MDM. Anal ultrasonography, anorectal physiology and proctography were performed in 96% of tertiary centres compared with 50% of non-tertiary units. CONCLUSION The provision of pelvic floor services includes local, regional and tertiary centres. The overall response rate was low (38%) and biased to centres with a consultant who was a member of the Pelvic Floor Society. Not all regional or tertiary centres held an MDM or a pelvic floor clinic. Given the nature of pelvic floor pathology an integrated service should be aimed at linking different centres and specialities.
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Affiliation(s)
- A J Hainsworth
- Pelvic Floor Unit, Colorectal Surgery, St Thomas' Hospital, London, UK.
| | - A M P Schizas
- Pelvic Floor Unit, Colorectal Surgery, St Thomas' Hospital, London, UK
| | - S Brown
- Colorectal Surgery, Northern General Hospital NHS Trust, Sheffield, UK
| | - A B Williams
- Pelvic Floor Unit, Colorectal Surgery, St Thomas' Hospital, London, UK
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Vrijens DMJ, Spakman JI, van Koeveringe GA, Berghmans B. Patient-reported outcome after treatment of urinary incontinence in a multidisciplinary pelvic care clinic. Int J Urol 2015; 22:1051-7. [PMID: 26264653 DOI: 10.1111/iju.12885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 06/25/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To assess patient-reported outcome and satisfaction regarding urinary incontinence 1 year after the end of treatment in a multidisciplinary pelvic care clinic. METHODS A total of 647 patients with urinary incontinence seen in an academic multidisciplinary pelvic care clinic were prospectively included in a specific triage system. Patient-reported improvement of urinary incontinence and patient satisfaction were assessed by telephone survey 1 year after the end of treatment. RESULTS Just 15.6% of patients presented with one single pelvic floor problem, most had two or three pelvic functional disorders simultaneously, such as urinary incontinence, pelvic organ prolapse and constipation or fecal incontinence. One year after the end of treatment, of 440 responders (68%), 18.2% reported no remaining complaints, and 33.4% reported only one complaint. Patients reported a significant improvement of the mean severity (scale 0-10) of urinary incontinence from 7.2 ±1.6 pretreatment (=T0) to 4.3 ± 3.0 1 year after the end of treatment (P < 0.001). A total of 20.6% of patients reported no urinary incontinence after 1 year (P < 0.001), and 27.6% (P < 0.001) stopped using incontinence pads. Patients claimed high satisfaction with the clinic and care received, with 35.8% being "satisfied" and 45.5% "very satisfied." CONCLUSION At 1 year after the end of treatment, one out of five patients with urinary incontinence recovered completely, and more than one out of four stopped using incontinence absorption pads. One out of three patients went from having a multifactorial health problem to a monofactorial health problem. High satisfaction rates were reported by more than four out of five patients.
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Affiliation(s)
- Desiree M J Vrijens
- Department of Urology, Maastricht University Medical Center, Maastricht, the Netherlands.,Pelvic Care Center Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jolanda I Spakman
- Department of Urology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Gommert A van Koeveringe
- Department of Urology, Maastricht University Medical Center, Maastricht, the Netherlands.,Pelvic Care Center Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bary Berghmans
- Pelvic Care Center Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
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Kapoor DS, Sultan AH, Thakar R. A Retrospective Review of Patients Seen in a Multidisciplinary Pelvic Floor Clinic. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:1028-1029. [DOI: 10.1016/s1701-2163(16)34707-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Chan MC, Schulz JA, Flood CG, Rosychuk RJ. In Response. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010. [DOI: 10.1016/s1701-2163(16)34708-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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