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Outcomes and quality-of-life measures in pelvic floor research

Introduction Outcome measures are the tools used to determine the efficacy, safety, and side effects of a treatment. Researchers assess outcome measures before and after treatments to determine their relative efficacy. Clinicians can use outcome measures to track the success of their treatments and/or longitudinally to follow the outcomes of individual patients. Urinary incontinence, fecal incontinence, pelvic organ prolapse (POP), and other pelvic floor disorders are…

Urology for the urogynecologist

Basics of urinary stone disease Introduction One out of 13 women will become symptomatic with a kidney stone in her lifetime; that incidence is rising in the United States resulting from the increasing prevalence of obesity and diabetes. Often, the symptoms are acute and painful, and require a visit to the emergency room. Unfortunately, half of patients who pass a kidney stone will have a recurrence…

Bladder drainage and urinary protective methods

Introduction Patients who undergo surgery for urinary incontinence or pelvic organ prolapse may require catheterization postoperatively because of voiding difficulty. Patients with neurogenic bladder, dysfunctional voiding, or intractable incontinence may require intermittent or indwelling catheterization for long-term management. Three catheterization methods—transurethral, suprapubic, and intermittent self-catheterization (ISC)—can be used. Surgeons may also recommend voiding trials for their patients postoperatively. Failure to void with voiding trials usually requires…

Lower urinary tract fistulas

Historic perspectives The earliest evidence of gynecologic fistula dates back millennia, to Queen Henhenit, one of the wives of King Mentuhotep II of Egypt (11th Dynasty, c. 2050 bc). In his dissection of the mummy at the Cairo School of Medicine in 1923, Derry noted a large vesicovaginal fistula (VVF) in the presence of a severely contracted pelvis; he concluded that the fistula was a consequence…

Urethral diverticula

Introduction For years, investigators who described their experience with urethral diverticula stated that more general awareness of this condition must prevail to improve its identification. Urethral diverticula can be difficult to diagnose. They are often overlooked as a source of recurrent urinary tract infections, chronic pelvic pain, and voiding dysfunction. The standard evaluation for all patients with acute and chronic pelvic disorders should include urethral diverticula…

Lower urinary tract infection

Introduction Urinary tract infections (UTIs) are one of the most common bacterial infections, affecting 150 million people each year worldwide. Annually, UTIs result in 10.5 million office visits (constituting 0.9% of all ambulatory visits) and 2 to 3 million emergency department visits in the United States alone. Within the United States, societal costs, including health care costs and time missed from work, are approximately $3.5 billion…

Interstitial cystitis/bladder pain syndrome

Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a heterogeneous and symptom-based condition marked by bladder or urethral pain and associated lower urinary tract symptoms, especially urinary frequency and urgency, in the absence of infection and other demonstrated pathology. Tremendous efforts have been made to gain an understanding of this disease, but the etiology remains unclear. This chapter will present current understanding and controversies surrounding nomenclature and…

Voiding dysfunction in women

Introduction Lower urinary tract dysfunction describes various problems related to the bladder’s ability to store or empty urine. Voiding dysfunction refers specifically to bladder emptying problems. Urinary retention is the inability to complete the voiding phase of the micturition cycle, and oftentimes represents the end stage of voiding dysfunction. Abnormal bladder emptying can occur as a result of dysfunction of the bladder or the outlet, and…

Neurourology and compliance abnormalities

Introduction The primary functions of the urinary bladder are storage and emptying, which are mediated by a combination of parasympathetic, sympathetic, and autonomic signaling (see Chapter 3 ). Bladder compliance is the ability of the bladder to accommodate changes in urinary volume during the storage phase, without a significant change in bladder pressure. Changes in compliance can result in a loss of bladder distensibility during bladder…

Refractory overactive bladder

Introduction Overactive bladder (OAB) is characterized by urinary urgency, with or without urgency urinary incontinence (UUI), usually with increased daytime frequency and nocturia, if there is no proven infection or other obvious pathology. The American Urologic Association (AUA) defines the refractory patient as the patient who has failed a sufficient trial of behavioral therapy and at least one medication (antimuscarinic or β-3 agonist) for 4 to…

Overactive bladder syndrome, polyuria, and nocturia

Overactive bladder syndrome Overactive bladder (OAB) is a symptom syndrome defined as urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia, and in the absence of urinary tract infection (UTI) or other obvious pathology ( ). Millions of Americans are affected by OAB at any given time, and the aging of the population ensures that the number of people who suffer from…

Full-thickness rectal prolapse

Introduction Full-thickness rectal prolapse is a benign but debilitating condition involving full-thickness descent of the rectum through the anal canal ( Fig. 30.1 ). It is important to distinguish full-thickness rectal prolapse from simple prolapse of the rectal mucosa on physical examination ( Fig. 30.2 ). This chapter will focus on full-thickness rectal prolapse. The true cause of rectal prolapse is unknown, despite its long and…

Rectovaginal fistula and perineal breakdown

Anatomy of the perineal body, distal vagina, rectum, and anus Perineal body defects and rectovaginal fistulas (RVFs) are part of a spectrum of conditions that impact the posterior pelvic floor. The surgical interventions used to address these defects must be based on a clear understanding of the anatomic structures involved. A postobstetric pinhole fistula may occur in isolation (i.e., the perineal body and anal sphincters [ASs]…

Constipation

Definition and etiology Constipation is a broad term that is defined as difficult evacuation of feces, infrequent defecation, or inadequate defecation. Our understanding of the etiology of constipation has improved, resulting in an evolving definition. One commonly used definition is based upon bowel frequency of fewer than three stools per week. This definition is based on interviews of factory workers in the United Kingdom that found…

Fecal incontinence

Epidemiology Fecal incontinence, the involuntary leakage of liquid or solid stool, and anal incontinence, including the involuntary leakage of gas, are devastating problems. Many people find these conditions socially incapacitating and stay home, minimizing social contact to avoid embarrassing situations. Estimates of the number of people afflicted with fecal incontinence likely underrepresent the prevalence, because many do not mention the problem to their caregivers, and health…

Complications of pelvic reconstructive surgery

This chapter discusses the evaluation, prevention, and management of many complications commonly associated with pelvic reconstructive surgery. Of note, it does not include a discussion of the evaluation and management of lower urinary tract injuries, which can be found in Chapter 24 , or management of mesh complications, which can be found in Chapter 25 . Evaluating comorbidities and perioperative risk Before a patient undergoes pelvic…

Managing mesh complications after surgeries for urinary incontinence and pelvic organ prolapse

Introduction Pelvic reconstructive surgery for genital prolapse and urinary stress incontinence usually results in improved quality of life ( ). However, numerous complications from mesh-augmented prolapse repairs, as well as placement of synthetic slings, have been reported in the literature. This chapter is aimed at discussing these various complications and how best to manage them. Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common…

Avoiding and managing lower urinary tract injuries during pelvic surgery

Introduction Lower urinary tract injury is one of the most serious complications of gynecologic surgery and, in addition to causing significant patient morbidity, is a common cause of litigation. Between 50% and 90% of all lower urinary tract injuries occur during gynecologic surgery because of the intimate anatomic relationship that exists between the female genital and lower urinary tracts. Review of the surgical literature reveals two…

Obliterative procedures for pelvic organ prolapse

Introduction As our population ages, pelvic floor disorders are becoming more prevalent and increasingly important health and social issues. Approximately 63 million women will be 45 years old or older by 2030, and 33% of the population will be postmenopausal by 2050. In the United States, the fastest growing segment in the population is women above 60 years of age. Approximately 11% of women will undergo…

Uterine preservation in pelvic organ prolapse surgery

Introduction Uterine prolapse is a common disorder in women. It represents the third leading cause of hysterectomy for benign disease and is responsible for approximately 70,000 hysterectomies annually in the United States, double the operation rate on women posed by mastectomies with reconstruction for breast cancer ( ). Given this large surgical volume, measures to increase the efficiency and safety of prolapse surgeries are paramount. Traditionally,…