The rise of Female Pelvic Medicine and Reconstructive Surgery as a distinct sub-speciality supports the need for a comprehensive education to Urology and Gynaecology trainees, encouraging a view of disease and dysfunction as conditions of the whole woman rather than of a limited organ system. While this is helping to promote high quality research and the improvement of treatment approaches of female patients, much remains to be done. Most women are not cared for by sub-specialists and lifelong learning is required for the generalist and specialist alike. As we move away from concentrating on our speciality defined organ systems, understanding the pelvic floor as a whole becomes the focus. Clinicians caring for female patients with pelvic floor disorders need to understand how to perform an efficient and accurate pelvic floor examination—for both anatomy and function. They need to be able to apply the information gained from the initial exam along with their knowledge of the relevant disorders to develop individualised treatment algorithms and improve the full spectrum of care. This will produce better patient outcomes.
There have been revolutionary changes in the field of female urinary incontinence and a plethora of evidence based guidelines and algorithms for diagnosis and therapy. Yet it is unclear to what degree patient outcomes are improving. Stress incontinent patients are confused by numerous treatment options and frightened of mesh slings. There is evidence that even basic pelvic floor muscle training is under utilised. Although many new medications have been introduced for overactive bladder, medication adherence remains low. Safe and effective advanced treatments have been introduced yet few patients are advancing to these “third tier” treatment options. There is a great need for urologists and gynaecologists to better understand the patient’s concerns and goals. Better phenotyping and individualised treatment programs may allow us to fully exploit the tools that are available to us now.
Pelvic organ prolapse is an extremely common condition with increasing prevalence as our population ages. Approximately 3% of women report symptomatic prolapse (bulge and/or discomfort) whereas prolapse is identified in 40-50% of women by examination. Approximately 300,000 women undergo prolapse repairs annually in the US and a woman’s lifetime risk for undergoing prolapse surgery has been estimated at between 11-19%. Although vaginal birth and hysterectomy are the major risk factors for prolapse, a great deal remains to be learned about the etiology, the cause of symptoms, and the natural history. Increasingly we are realising that pelvic organ prolapse may be a chronic condition in need of continued management. The push to improve surgical outcomes by employing permanent mesh implants backfired in a morass of lawsuits and withdrawn products. Urologists and gynaecologists have a great need to incorporate the (significant) tangible knowledge that was gained from reports and trials during the mesh era to provide clear counselling and quality treatment for prolapse patients. Current treatments are imperfect, but very good options exist for almost all prolapse patients and the vast majority can safely achieve relief of their symptoms.
Neurogenic bladder (NGB) is a non-specific, widely overused and misunderstood term. It only communicates that a patient with an abnormality of lower urinary tract function has a clinically relevant neurological disorder. Unfortunately, this comprises such a heterogeneous group of both diseases and functional problems as to be of little use. There is still no useful classification system for NGB disorders. It is imperative that clinicians use the best available evidence to provide quality care including accurate diagnosis, effective patient centred treatment and individualised follow-up plans that protect renal health while minimising patient burden.
Most of the attention in FPMRS training and research is on urinary incontinence and pelvic organ prolapse. But the field is very broad and a great many more disorders and diseases cause significant patient morbidity. Urologists and gynaecologists need to be aware of the following issues to provide their patients with the best possible care:
• uncommon but clinically important urethral pathologies
• management of urinary tract trauma and fistulae
• the ubiquitous but medically ignored symptom of nocturia
• the conundrum of bladder pain
• the devastating problem of faecal incontinence
At the conclusion of the ICS Regional Course 2017: North America, attendees should be able to:
- Efficiently evaluate an incontinent woman including and accurate pelvic floor exam for anatomy and function and simple bedside stress testing.
- Effectively employ conservative measures—behavioural, pharmacological, and devices—in treatment of female urinary incontinence.
- Counsel “index” stress incontinent women for surgical treatment with bulking agents, mesh slings, and fascial slings.
- Describe the “third tier” treatment options for refractory OAB with the pros and cons of each.
- Manage the evaluation and treatment of patients with lower urinary tract trauma.
- Identify nocturia as a symptom not a disease. Calculate NPI and perform basic classification of nocturia to provide relevant treatment or referral.
- Identify common phenotypes of Interstitial Cystitis/Bladder Pain Syndrome so as to provide effective, individualised care.
- Increase identification of faecal incontinence, provide relevant basic evaluation and treatment.
- Identify common indications for advanced urodynamic investigations and follow good urodynamic practices in performing such studies.
- Compare and contrast the types of lower urinary tract disorders associated with the most common neurological diseases.
- Identify patients with “safe” neurogenic bladders who may be managed symptomatically vs. those who require active follow-up and more aggressive intervention.
- Apply knowledge of pelvic floor anatomy and function in the operating room to produce better patient outcomes.
- Identify tangible knowledge that was gained from reports and trials during the mesh era to provide clear counselling and quality treatment for prolapse patients.
- Identify and manage common important urethral pathologies—caruncles, cysts, diverticuli and strictures.