Pelvic Floor Disorders: Surgical Approach

1. The Multidisciplinary View of a Pelvic Floor Unit

Christopher Cunningham 

(1)

Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK

Christopher Cunningham

Email: chriscunningham@nhs.net

Abstract

This chapter aims to highlight the importance of an integrated approach to pelvic floor (PF) practice. This facilitates adequate assessment of conditions across the three pelvic compartments, carefully selecting those patients who may benefit from surgery, optimizing conservative management preoperatively, and improving function postoperatively, as well as understanding and supporting the social, psychological and sexual impact of PF conditions. Creating a robust multidisciplinary team (MDT) offers advantages to both patients and healthcare providers, and is a defining feature of an established PF service.

1.1 Introduction

This chapter aims to highlight the importance of an integrated approach to pelvic floor (PF) practice. This facilitates adequate assessment of conditions across the three pelvic compartments, carefully selecting those patients who may benefit from surgery, optimizing conservative management preoperatively, and improving function postoperatively, as well as understanding and supporting the social, psychological and sexual impact of PF conditions. Creating a robust multidisciplinary team (MDT) offers advantages to both patients and healthcare providers, and is a defining feature of an established PF service.

1.2 Core Members of the MDT

The PF MDT needs to be inclusive. Surgical input should be provided by colorectal surgeons and appropriate specialists to cover urological and gynecological needs, and in many institutions this will be provided by a urogynecologist. However, a proportion of patients will be male or require specific expertise that can only be provided by a urologist with an interest in functional conditions. It is valuable to have more that one representative from each subspecialty but smaller services may be unable to achieve this. The MDT should have a clinical lead and administrative infrastructure to support audit and research. Core membership should contain PF physiologist and specialist nurses. This is the heart of the MDT through which patients are assessed and investigated, as well as introducing advice and conservative management at an early stage. The increasing use of neuromodulation (sacral nerve stimulation and posterior tibial nerve stimulation) demands highly trained individuals to motivate patients and optimize treatment. The PF nurse is ideally placed to deliver these treatments and explore the use of other approaches such as retrograde irrigation. Everyone involved in a PF practice is aware of the sensitive nature of the conditions and the potential relationship to psychological and sexual problems. Sexual abuse can be a significant etiological contributor to PF dysfunction and all members of the MDT need to be aware of opportunities to explore this; however, it is most often the PF nurse who is able to foster the close relationship and create the best opportunity to for this. Many relationships suffer the consequences of sexual problems as a result of PF dysfunction, particularly fear of leakage and pelvic pain during intercourse. Considerable support is needed to help women and their partners understand and cope with these difficulties. This can be provided by any member of the team with regular patient contact; however, it is often the specialist nurse who establishes rapport with patients to facilitate these discussions.

Good communication with obstetric and midwifery teams is important although they need not be core members of the MDT. This allows shared protocols for management of PF conditions early in the postpartum period, deciding who should be responsible for the management of acute pelvic floor and sphincter injuries and offering patients a seamless pathway of care to the colorectal service if problems persist. Clear guidelines and protocols are helpful in defining indications for caesarian section and vaginal delivery in patients with persisting PF problems either from previous obstetric injury or those with gastrointestinal conditions, e.g., previous or anticipated ileal pouch surgery in ulcerative colitis or polyposis.

A dietician with an understanding of PF abnormalities will support advice given through biofeedback and ensure that all members of the MDT present consistent and accurate advice to patients. Many patients with constipation and PF conditions have a background of “irritable bowel syndrome” in which dietetic input is invaluable. Dieticians also play an essential role in managing more challenging cases, e.g., those patients with eating disorders contributing to prolapse, constipation, and obstructed defecation.

PF complaints are more common in patients with functional gastrointestinal conditions such as irritable bowel syndrome, delayed transit, and gastroesophageal reflux disease; indeed, many patients with these diagnoses have underlying PF dysfunction such as obstructed defecation. Involvement of a gastroenterologist facilitates a holistic assessment, optimizing management of patients with combined pathologies.

Expert radiologist involvement provides reliable interpretation of defecating proctography and magnetic resonance imaging defecography, and provides training such that the entire clinical team can interpret these investigations in the context of the clinical presentation. Moreover, the whole radiology team plays an important part in getting the most out of these procedures. Patients regard proctography as one of the most embarrassing and potentially humiliating investigations; creating a relaxed, caring, and sensitive environment for these examinations is critical for reasons of patient compliance and comfort, and achieving high-quality radiology.

Finally, the PF MDT needs access to expertise in chronic pain management, rehabilitation, and psychological and psychiatric assessment and treatment. While this is only required on a formal basis in a minority of patients, discussion of these issues leads to awareness and education of the entire team in techniques of managing the complex problems that surround chronic PF conditions.

The MDT provides the engine room for a high-quality PF practice, demonstrating robust clinical governance and an evidence-based approach to practice and critical assessment by research and audit. Moreover, the concentration of expertise provides a fruitful environment for training and education.

1.3 Starting a PF MDT

The preceding description may set challenging standards for those embarking on a PF practice or those working in an environment where all facilities (e.g., anorectal physiology) are not available. It is useful for small, developing MDTs to be aligned with an established MDT in a “hub and spoke” arrangement. Most mature MDTs will welcome engagement with smaller affiliated units driven by an interest in improving access to high-quality PF services. Within the UK this has progressed to developing regional groups with regular meetings to discuss clinical and research matters around PF practice, generating guidelines and standards for clinical practice.

At a local level, it may be reasonable for the MDT to meet on a monthly basis to discuss interesting or challenging cases and particularly provide follow-up on previously discussed clinical problems and decisions. This is an excellent environment for the team to develop expertise collectively. An alternative strategy is to combine the MDT with a PF clinic. This allows effective delivery of MDT decisions directly to patients, and efficient assessment of patients by different specialties at the one clinic. The optimum way of developing this depends on local practice and commitments of specialists and supporting staff. However, the benefits of creating a definite identity for the PF MDT cannot be overstated. It provides a focal point for referrals, training, education, and research.

1.4 What are the Objectives of PF MDT?

1.4.1 Efficient Patient Pathways and Algorithms

The most obvious objective is to provide patients with the best experience of healthcare, avoiding unnecessary re-duplication of clinical assessment and investigations, and optimizing function with nonoperative approaches, and for those requiring surgery we should aim to offer procedures under a single anesthetic. This may require two disciplines operating together to offer patients sensible and appropriate surgical combinations and the best chance of improving outcome. This makes sense from a health economics view and is more convenient for patients; however, it needs a functioning and cooperative MDT structure, and resolution of these difficulties is often political rather than clinical.

Colorectal surgeons and urogynecologists will share many patients with related PF conditions and PF MDTs are often borne out of combined clinics to manage those patients with most severe conditions. Discussing patients in a common forum leads to an understanding of how the same pathology (e.g., rectocele) can be present with diverse symptoms (e.g., obstructed defecation or dyspareunia) for which the treatment may be the same or entirely different as determined by associated symptoms or signs, e.g., co-existing internal rectal prolapse. A multidisciplinary approach encourages clinicians to explore the impact of PF problems more widely and consider combined operative approaches that are perhaps more likely to benefit the patient with multiple symptoms.

1.4.2 Clinical Governance and Audit, and Protection from Litigation

It is important for professional and medico legal reasons that all conservative measures have been explored thoroughly before proceeding with surgical treatment. Many patients miserable with symptoms of PF pathology are looking for a “quick fix” and, although at times frustrating, it is important that we demonstrate that maximum conservative management has been undertaken and supported by the MDT. This offers patients the additional benefit of optimization before surgery and preparation and counseling for postoperative care and expectations. Managing expectations is an important aspect that is supported by the MDT as a whole, i.e., all members of the team understand treatments and provide consistent and noncontradictory advice. This means establishing what outcomes can be expected from surgery based on evidence available, and also exploring what options are available if surgery is not successful or the condition is aggravated by surgery or its complications. The patient who is seeking to improve quality of life must be aware of the chances that complications from PF surgery may impair quality of life; for example, urgency after stapled transanal resection or mesh infection or erosion after rectopexy. Patients should be encouraged to consider that surgery could make them worse.

It is valuable to maintain a database of patients, conditions, and treatment from the earliest stages of a pelvic floor practice. This is useful for internal audit and considering outcomes and complications against published standards. Treatments and particularly surgical intervention offered to improve quality of life should be demonstrably successful and the only way to record this is through patient-reported outcomes with validated PF function questionnaires. These need not be overly complex but some record of outcome and incidence of complications is imperative.

1.4.3 Training and Continuing Education

Concentrating expertise and developing a careful practice based on best evidence will create a rich environment for trainees from medical and paramedical disciplines to gain competence in the assessment and management of PF conditions. Over the last 5 years, PF practice has gained a new appreciation among trainees, not least because of the increased options available to treat these complex conditions and it is certain that the subspecialty is gaining credibility, through setting up regional, national, and international societies. Enthusiastic trainees are searching for organized PF clinics offering a modern approach to managing these complex cases, and which are able to offer the highest standards of care and training.

1.4.4 Conclusions

It is an exciting time in colorectal surgery and PF practice in particular. The last decade has seen a tremendous expansion in interest and therapeutic opportunities in PF conditions. Many women who were relegated to suffering in silence or resorting to a stoma are now improved with careful advanced conservative treatments and minimally invasive surgical procedures. The multidisciplinary approach to PF conditions has been at the heart of this revolution in management and is the foundation for the introduction of future novel approaches.

Suggested Reading

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