The future of pelvic floor services in the UK

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic

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.

Is there any association between symptoms and findings on imaging in pelvic floor defaecatory dysfunction? A prospective study

AIM

To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction.

METHOD

A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co-ordination, evacuation) features were examined.

RESULTS

Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ-VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire - Bowel Symptoms (ICIQ-BS) bowel pattern score in those with a rectocele, and a lower ICIQ-BS bowel pattern and sexual impact score in those with intussusception. Poor co-ordination was associated with increased ICIQ-BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ-VS symptom scores were lower in patients with poor co-ordination.

CONCLUSION

Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.

Position statement by the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland on the use of mesh in ventral mesh rectopexy

The following position statement forms part of a response to the current concerns regarding use of mesh to perform rectal prolapse surgery. It highlights the actions being pursued by the Pelvic Floor Society (TPFS) regarding clinical governance in relation to ventral mesh rectopexy (VMR). The following are summary recommendations. Available evidence suggests that mesh morbidity for VMR is far lower than that seen in transvaginal procedures (the main subject of current concern) and lower than that observed following other abdomino-pelvic procedures for urogenital prolapse, e.g. laparoscopic sacrocolpopexy. VMR should be performed by adequately trained surgeons who work within a multidisciplinary team (MDT) framework. Within this, it is mandatory to discuss all patients considered for surgery at an MDT meeting. Clinical outcomes of surgery and any complications resulting from surgery should be recorded in the TPFS-hosted national database (registry) available for this purpose; in addition, all patients should be considered for entry into ongoing and planned UK/European randomized studies where this is feasible. A move towards accreditation of UK units performing VMR will improve performance and outcomes in the long term. An enhanced programme of training including staged porcine, cadaveric and preceptorship sessions will ensure the competence of surgeons undertaking VMR. Enhanced consent forms and patient information booklets are being developed, and these will help both surgeons and patients. There is weak observational evidence that technical aspects of the procedure can be optimized to reduce morbidity rates. Suture material choice may contribute towards morbidity. The available evidence is insufficient to support the use of one mesh over another (biologic vs synthetic); however, the use of polyester mesh is associated with increased morbidity.

The impact of pelvic floor multidisciplinary team on patient management: the experience of a tertiary unit

Purpose

Pelvic floor dysfunction is a common and heterogenous condition with numerous clinical manifestations, making the optimal management challenging. The traditional single-specialty approach may fail to address its complex nature. Currently, there are no published data on the impact of joint pelvic floor multidisciplinary team (MDT) meetings on patient management.

Patients and methods

This study represents a retrospective analysis of prospectively collected data on female patients discussed at a joint pelvic floor MDT over a 12-month period in a tertiary referral center.

Results

One hundred fifty-two cases were included with a median age of 55 years (range 18-83) and a BMI of 32 kg/m² (range 17-58). Lower urinary tract dysfunction was the predominant symptom in 75% (114/152). The pelvic organ prolapse symptom of a vaginal bulge was present in 11% (17/152). All cases of vaginal prolapse were accompanied by either urinary incontinence, 59% (10/17), or obstructive defecation, 41% (7/17). Fecal incontinence was recorded in 10% (15/152). Mesh-related complications were reported in 3% (4/152). The MDT recommended a change in the initial management plan in 20% (31/152) of cases, of whom 80% (25/31) were patients with complex urinary incontinence. The MDT agreed a change in the primary care team in 16% (25/152) of cases.

Conclusion

There is an increasing regulatory requirement for patients with pelvic floor dysfunction to be discussed in an MDT setting. Findings demonstrate that joint pelvic floor MDT meetings are feasible and contribute to a change in the management of complex patients.

Barriers to the management of obstructed defaecation according to colorectal surgeons

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.