1. Can Pelvic Floor Dysfunction be Managed Surgically?

2. Educational Objectives At the end of this presentation the surgeon will be able to list and compare success rates for the surgical treatment of pelvic floor dysfunction. This lecture will enable participants to choose appropriate treatment regimens for various types of pelvic floor dysfunction

5. The magnitude of the problem Pelvic floor dysfunction is a major health issue for American women. 11% lifetime risk of surgery for pelvic floor dysfunction Re-operation is common—(30%) The time interval between repeat procedures decreases with each successive repair (Olsen,1997)

6. Cost to society?? The annual direct cost for treating urinary incontinence alone in the U.S, is over 16 billion dollars. (Wilson 2001) * Over the next thirty years the demand for treatment will increase twice the rate of the population growth. (Luber2001)

9. Principle categories of pelvic floor dysfunction Urinary incontinence anal incontinence Pelvic organ prolapse Sexual dysfunction

10. Mechanism of pelvic floor damage As common as childbirth!!! Stretching or attenuation? Breaks in the endopelvic fascia Injury to pelvic muscles Injury to pelvic nerves

15. Nerve damage? 95% of women with stress urinary incontinence have prolonged pudendal nerve conduction times 4% of women without stress incontinence have prolonged pudendal nerve conduction times. (Smith 1989)

16. Mechanism of Neural Damage A peripheral nerve sustains permanent damage when it is stretched greater than 12% of its length A pressure of 80 mm hg can produce complete cessation of blood flow through the perineurium. Pressure between the fetal skull and the lateral pelvic wall can reach 322 mm hg Heavy lifting or straining at stool can produce stretch and pressure damage

18. Surgical Treatment Every honest surgeon of extensive and long experience will have to admit that he is not entirely and absolutely satisfied with the long term results of his operations for prolapse and allied conditions. Telinde(1922)

22. Urinary incontinence—how good are we?? Procedure 1 year 5 years Burch 92% 86% Ant repair 64% 45% Needle proc 70% 45% PV slings 90% 85% TVT 92% 86%

24. How good are we with surgically managed anal incontinence? What is the magnitude of this problem? 5% of the population without bowel disease report loss of solid stool 7% report incontinence of liquid stool 12% report incontinence of flatus (Giebel 1988) Anal incontinence is the second leading cause of nursing home placement The cost is over seven billion per year

25. How good are we at surgical correction? 60 % of women with anal incontinence will have prolonged pudendal nerve conduction 62% with normal nerve studies can expect a “successful “ surgical outcome 16% with abnormal pudendal conduction studies can expect a successful surgical outcome Overall success rate at five years was 49% (Gilliland,1999)

26. Posterior compartment defects Vaginal bulge relieved 76-96% Vaginal splinting relieved 50-70% 20-50 % develop dyspareunia (Porter, 1999)

28. Sexual Dysfunction 17% of women who suffer from anal incontinence do so during sexual intercourse (Gjessing, 1998) 7.5% of women who deliver vaginally develop permanent dyspareunia (Goetsch, 1999) Those with third or fourth degree lacerations were 3X as likely to develop dyspareunia 20-50% of women will develop dyspareunia after a posterior repair (Porter,1999)

29. Is this new? As obstetric specialists we must lead the way in improvements of our art, for it is still capable of improvement. The public is demanding with a voice that becomes louder and more distinct each year for relief from the dangers of childbirth for the childbearing woman. ( De Lee, 1920)

30. How can we improve as a Specialty? We should practice obstetrics with gynecology in mind and gynecology with obstetrics in mind. Linda Brubaker

31. Surgical treatment of urinary incontinence We do a pretty good job!! More surgical failures result from poorly chosen procedures than poorly performed procedures Match the procedure to the patient—not the patient to the procedure A systematic evaluation of all patients Decrease the frequency of procedures with poor success rates More liberal use of non-surgical therapy

32. Non-Surgical therapy for urinary incontinence Agency for Health Care Policy and Research recommends that non-surgical therapy be attempted in nearly all patients with urinary incontinence before surgical therapy is instituted. Even though surgery promises the highest chance of success, it somewhat limits future options Non-surgical therapy will cure 10% of patients with SUI and improve another 40% Not everyone buys this!!!!

35. Surgical treatment of anal incontinence We are not so impressive here!! How can we improve? Neurodiagnostic studies Imaging studies Medical treatment

36. Opinion!!! Most anal incontinence has a major neurological component, and our understanding of the neurophysiology and pathophysiology of the pelvic floor and gastrointestinal tract is poor. Outcomes in the presence of neurological deficits are generally poor Never miss a chance not to operate on a patient with anal incontinence.

38. Non surgical therapies Biofeedback Sacral nerve stimulation Pudendal nerve modulation Transanal electrical stimulation Pulsed electromagnetic fields

40. Biofeedback Most effective in patients with partial enervation of the sphincters and preservation of rectal capacity Can be augmented with electrical stimulation (Fynes, 1999)

41. Medical Management Avoid stimulant laxatives Fiber is not always the answer! Do not overlook the benefits of exercise!!

43. Practice obstetrics with Gynecology in mind Do a better post partum examination PISQ-12 53% of women with anal incontinence had significant deterioration after subsequent vaginal deliveries 40% of those with transient anal incontinence had return of symptoms with subsequent deliveries

44. More bad news 42% of women who were asymptomatic, but had sonographic evidence of sphincter disruption developed symptoms with subsequent vaginal deliveries 76% of women with sphincter defects greater than 90 degrees, or squeeze pressures of less then 20 mm hg developed symptoms with a second vaginal delivery ( Fynes 1999)

46. Rectocele repair Interpositional grafts?? Dyspareunia decreased 20% Constipation decreased 50% Fecal incontinence decreased 10% Miclos (2003)

52. Sexual dysfunction PISQ-12 You can’t help if you don’t ask Improvement in desire, performance, and achievement of orgasm were reported in women who received pelvic floor rehabilitation. (Nezihe, 2003) If you improve continence you generally improve sexual function

53. Conclusion When it comes to pelvic floor dysfunction, Newton, Darwin,and Murphy were all right. Never miss an opportunity to treat pelvic floor disorders conservatively. Anything you do in obstetrics and gynecology can lead to complications (Mc Caws’ Law) The lesser the indication the greater the complication. (Lyles’ Law)

55. Selected Reading Surgery and Patient choice: the ethics of decision making. ACOG Committee opinion No289, Nov 2003. Fynes M, Donelly V, Behan M. Effect of second vaginal delivery on anorectal physiology and fecal continence: a prospective study, Lancet,vol354,983-986, Sept 18, 1999 Sze E, Sherard G, Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol v 100, no5, 981-986, 2002 Rogers R, Coates K, Kammer–Doak D, et al. A short form of the Pelvic Organ Prolapse/ Urinary incontinence- sexual Questionnaire (PISQ-12). Internat Urogyn J :14. 164-168, 2003

57. The End----Questions???