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Organising a clinical service for patients with


pelvic oor disorders
Dave Chatoor, Research Fellow
a
, Marco Soligo, Consultant Gynaecologist
b
,
Anton Emmanuel, Senior Lecturer & Honorary Consultant
a,
*
a
University College London, United Kingdom
b
University of Milan, Italy
Keywords:
multidisciplinary team
algorithms
obstetric trauma
pelvic organ prolapse
chronic pelvic pain
The evolution of the multidisciplinary approach to the manage-
ment of chronic conditions is a reection of how medicine has
evolved from a singular to a plural effort recognising the complex
causations and consequences of such disorders. This thinking
should not be conned to tertiary centres alone and should be
adapted where local expertise is available. Such an approach is
especially important in pelvic oor disorders, where the correla-
tion between structure and function is not always straightforward.
There is a need to avoid over-investigation by accurate clinical
assessment allied to tailored investigation, leading to a step-wise
approach to treatment (which may include behavioural, physio-
therapy, medical or surgical management). The algorithms here on
faecal incontinence, obstetric trauma, pelvic oor prolapse and
chronic pelvic pain attempt to provide such a logical approach to
patients.
Crown Copyright 2009 Published by Elsevier Ltd. All rights
reserved.
Introduction
The importance of adopting a multidisciplinary approach to the pelvic oor is self-evident from
studying the contributions to this volume. This is true both for patients with functional pelvic oor
disorders and for those with specic disorders (neurological, post-obstetric). A blinkered focus
* Corresponding author. GI Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, United
Kingdom. Tel.: 44 (0)207 380 9311; Fax: 44 (0)207 380 9329.
E-mail address: a.emmanuel@ucl.ac.uk (A. Emmanuel).
Contents lists available at ScienceDirect
Best Practice & Research Clinical
Gastroenterology
1521-6918/$ see front matter Crown Copyright 2009 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpg.2009.06.004
Best Practice & Research Clinical Gastroenterology 23 (2009) 611620
specied by the connes of ones speciality and perceived limited options for treatment is unlikely to be
able to address the multiple causations and consequences of dysfunction in this complex and physi-
cally intimate area. As we develop an expanding knowledge base of effective investigation and
management techniques towards patients with pelvic oor symptoms, there will be an increased
emphasis on multi-agency management of pelvic oor dysfunction. This change, allied to a focus on
quality of life issues and psychological well-being, should result in an improved outcome for such
patients. Taken together, this means that, for example, patients presenting with constipation, should
get assessed not just for aspects of colonic motility and rectal evacuatory function, but also be asked
about symptoms of urological and gynaecological dysfunction.
The concept of a multidisciplinary team (MDT) meeting arose from the treatment of malignant
conditions and from gerontology practice, where several healthcare disciplines provide a shared
opinion on the optimal management for each patient. This allows for, and indeed requires, the
development and implementation of clear algorithms for specic symptoms or for complex disorders.
In addition there are advantages in terms of facilitating the process of referral and cross-referring.
Finally, the MDT allows the opportunity to develop a research strategy and facilitate study recruitment
and development of new services.
This concluding chapter of this edition is to summarise the previously presented evidence into these
four areas:
(a) Diagnostic services which tests are essential, which are occasionally needed.
(b) Conservative treatments which modalities, and when.
(c) Organising multidisciplinary teams for pelvic disorders.
(d) Algorithms for managing complex cases.
Diagnostic services which tests are essential, which are occasionally needed
Why order a test?
Medical testing represents an essential part of clinical practice, its common uses being to support
clinical suspicions, to identify prognostic factors, to help guide therapy, to assess ongoing treatment,
reassess worsening symptoms and lastly for medicolegal assessment and documentation. Examples in
this supplement include pelvic oor physiology (anorectal physiology, urodynamics), imaging (static/
dynamic, endocavity MRI and ultrasound, uoroscopic proctography and transit studies), nuclear
(evacuation scintigraphy), endoscopy (sigmoidoscopy and colonoscopy).
Fundamental to all these aspects is that prior to any testing, comprehensive clinical assessment is
required. History taking and examination techniques are outside the scope of this volume, but it is
important for units to consider using validated questionnaires and scores to assess symptom burden
and impact on quality of life [1]. There are condition specic instruments for example that used in
neurogenic patients (neurogenic bowel dysfunction score), pelvic organ prolapse (International
Consultation on Incontinence Modular Questionnaire for Vaginal Symptoms: ICIQVS) and generic
ones which have been cited in the preceding articles; examples include: for incontinence (Wexner
incontinence score), for constipation (Wexner constipation score), quality of life short form (SF-36,
SF-12), HAD (hospital anxiety and depression score).
Organising and choosing tests
Tests on the pelvic oor and its compartments can be divided into those tests that are essential in
almost all patients and those that are only occasionally needed. Essential tests can be further sub-
divided into those that are urgent or non-urgent. Urgent investigations are often used to assess
suspicious symptoms; examples include cystoscopy for haematuria, colonoscopy for change in bowel
habit and/or rectal bleeding, CT abdomen for an abdominal mass.
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 612
Essential tests also need to be clinically appropriate and not just done by rote; if the patient can be
treated without the test being done one should question why the test is being done at all. The algo-
rithms below follow the trend of urgent investigations to exclude sinister causes followed by simple
conservative management for those who have no organic disease identied. Only if symptoms persist
should specic further testing be undertaken.
Patient counselling is imperative prior to testing. In our practice we encourage referring physicians
to talk to the patient about what the tests are likely to involve and any risks they may have. Patients
would then be sent a patient information leaet explaining in some detail what the tests involve, any
preparation they need to have, where they need to come and howlong the tests will take. On the day of
testing again the patient is taken through what the test involves and any queries answered. Such
repetition is essential tooptimise attendance and subsequent comfort for the patient who presents with
deeply personal symptoms associated with pelvic oor dysfunction. Some procedures require patient
consent; this can take the formof implied, verbal or written consent depending on the test, its invasive
nature and likelycomplications that could arise. There is often a legal requirement for a chaperone to be
present for any intimate examination or invasive testing. In a research setting often specialist tests are
performedandthese will require special consent forms for the appropriate study; patients must be clear
on what tests are routine and which are research oriented. Sometimes published work on specic tests
are benecial but not yet part of global practice; these special tests are often in the realm of tertiary
centres and may need approval fromthe local health authority, ethics committees or regulatory bodies
that govern testing. As part of clinical governance the outcome and safety of tests being undertaken
should be published both by way of quality control and to inform other centres of ones experience.
Above all, whether research oriented or not, the patient should understand why the test is being per-
formed, how it will aid their diagnosis via exclusion or inclusion and how it will aid their treatment.
Over testing
This is always a risk typically in patients who either have not found a favourable explanation for
their symptoms or who have been seen at multiple tertiary institutions having the same investigations
at specialist centres. It is important to identify the patient at risk of over testing; these are often
patients with functional pelvic oor disorders, chronic pain syndromes and underlying psychological
disorders. Clinicians are as much to blame as patients; often one feels compelled to do something by
ordering a test and similarly patients feel that they are not being taken seriously if tests werent
ordered for them. Patients assume the sick role and this is particularly so in the context of functional
bowel disorders, where often there is therapeutic testing to reassure the patient.
Conservative treatments which modalities, and when
Conservative management of patients symptoms applies to both physicians and surgeons, the latter
of course should not feel compelled to operate as rst line, as these conditions are primarily benign
conditions, though they can be severely life restricting. Conservative therapies are not only limited to
drugs; it takes into consideration treating the patient as a whole, tending to the physical and psycho-
logical effects that can be either a result of, or in some cases the cause of the symptoms they are expe-
riencing. Conservative therapyis indicatedeither whensurgeryis not initiallyindicatedor secondlyafter
surgery mayhave failedwithfewother options toconsider. The commonconservative options discussed
in the supplement include: (1) diet and lifestyle modication which forms part of behavioural modi-
cation; (2) medical therapy which includes suppositories/enemas for evacuation and anti-diarrhoeals
for incontinence as examples; (3) pelvic oor physiotherapy and Kegel exercises; (4) biofeedback (with
or without electronic aids); (5) psychological supportive treatment.
While the above treatments are commonly employed, it is difcult to prove the efcacy for many of
them as it is difcult to undertake a pure placebo-control study as some of these symptoms are
heterogenous and commonplace [2,3]; end-points need to be both objective (radiology or physiology)
and subjective (symptom scores, QoL); denitions of conditions (e.g. evacuation difculty) and treat-
ment (e.g. biofeedback) vary between institutions. However with this in mind we should aim to use all
available resources in an MDT format where indicated particularly in complex cases. The algorithms try
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 613
to simplify the management of common conditions discussed in this supplement and conservative
treatment is often rst line in the majority of cases.
Organising multidisciplinary teams for pelvic disorders
The multidisciplinary team approach is a means of synchronising treatment between various
specialities and streamlining the patient pathway. A systemof cross-referral of patients is enhanced by
regular face-to-face meetings between specialists in the core areas of colorectal surgery, urogynae-
cology, urology, pain, psychology and functional gastroenterology. Membership is vitally beyond
simply doctors, with incontinence nurse specialists, pelvic oor physiotherapists, biofeedback nurses,
physiologists all having distinct skills central to the assessment and management of these patients with
often multiple decits. The clinical experience and medical evidence of this diverse group inform the
details of management of these patients. The frequency of meetings will depend on the patient load
and referral practice in any individual unit. Presentation of each case individually followed by expert
review of radiology and any physiology helps dictate the subsequent care of each individual. Docu-
mentation of the decision in the case records immediately at the time is essential, in our opinion.
Complications and potential complications of any interventions are discussed at these meetings.
This is especially valuable in formulating and rening research projects in this often complex patient
group. The meeting also has an educational aspect with frequent audits, research presentations and
guest speakers invited.
The MDT approach should not be thought of as being restricted only to a tertiary setting. While
some of the specialist expertise may not be widely available, it is still a valuable way of managing
difcult cases as well as streamlining management. In the decades gone by, the surgeon or physician
often dictated all the management for that patient and saw through all steps from the beginning.
Medicine has become a more diverse subject and changes in specialist training reect this. It pertains
not only to medical training but also to specialist nurse training, physiologists and physiotherapists.
Successful attendance and participation in these meetings are only possible by making themboth xed
in dates and chaired evenly.
It is important to realise that the MDT approach is not just a once monthly meeting, it is a philos-
ophy. It is about developing pathways based on locally available expertise that is evidence based,
streamlining cross-referral guidelines, developing guidelines through research and audit and ulti-
mately, it is about working together as a group to achieve the same goal. Importantly, algorithms need
to be exible as new information and procedures become available.
Algorithms for managing complex cases
The following algorithms address some of the common themes addressed in this supplement that
the gastroenterologist is likely to encounter: obstetric pelvic oor injury, faecal incontinence, con-
stipation, chronic pain and pelvic organ prolapse. It is important to realise that the algorithms are
simplied so one can follow the general pathways that the patient may follow, and is meant to be
a guide to management. The algorithms are divided into compartment specic or region specic
management; however symptoms often overlap and many of these pathways are often conducted in
parallel. Although the order of management is presented from conservative rst through to inter-
ventional, depending on symptom severity and the anatomical and functional abnormalities, some
steps will need to be bypassed. These conditions are explained in further detail in the relevant chapters
in this supplement and only brief explanations of the algorithms are given here.
The algorithm in Fig. 1 explains how we manage patients with faecal incontinence. It is important to
exclude organic causes of faecal incontinence, that may be related to sinister symptoms (e.g. change in
bowel habit, diarrhoea, weight loss, tenesmus) and reversible causes such as infectious diarrhoea and
microscopic colitis. Initial management consists of practical advice (pads, odour control, sphincter and
pelvic oor exercises and advice on a low residue diet if stool is loose) and titrated loperamide [4]. If
symptoms persist or there is suspicion of a structural abnormality, patients should undergo structural
assessment using endoanal ultrasound; this will inform us of sphincter tears and atrophy. MRI is partic-
ularly sensitive for looking at the skeletal muscle if this is poorly seen on ultrasound. Dynamic MRI or MR
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 614
proctographyis useful inassessing pelvic oor weakness andthe other vaginal compartments for prolapse
as incontinence might be part of global pelvic oor weakness. Two thirds of patients will improve
with biofeedback, which is indicated either as rst line treatment or for those who fail surgery. It offers
a holistic approachto these often desperate patients [2]. Rectal irrigation is particularly useful for patients
with a neurogenic bowel (MS and spinal injury) [5]. For the elderly a common cause of incontinence is
faecal impaction; for these it is important to encourage regular toileting often using stimulant supposi-
tories or regular enemas. The success of sacral neuromodulation has brought it up higher inthe algorithm
with less reliance on complex/salvage procedures such as articial bowel sphincter and graciloplasty.
Obstetric trauma occurs in one third of primigravidas, 13% of these are symptomatic and 1% of these
will have a third degree tear or worse [6] (Fig. 2). Patients with occult injuries are also at risk of further
tears; one should have a high level of suspicion in those who have had an operative delivery, transient
symptoms (faecal urgency and atus incontinence), or in those with a suspected third degree tear on
rectal examination[7]. Endoanal ultrasoundandanorectal physiology informthe algorithmandpatients
who are symptomatic with a primary or persistent defect should be considered for a sphincter repair.
The important question is what should be the future mode of deliveries in the context of perineal
trauma. There is little grade 1A evidence to give us denite advice; however the Royal College of
Obstetricians suggests that if the woman is symptomatic or shows abnormal anorectal manometric or
endoanal ultrasonographic features, it may be advisable to offer an elective caesarean section [8]. The
risks and benets of a caesarean section vs vaginal delivery should be discussed by the obstetrician and
the patient offered an informed choice based on emerging evidence on obstetric trauma and best
management.
The algorithm in Fig. 3 complements Chapter 5 in this supplement. Constipation symptoms can be
very common, but more importantly they can compliment sinister symptoms. A distinction should be
made between the two and red ag symptoms investigated (weight loss, abdominal mass, symptoms
of anaemia, and rectal bleeding). Simple advice can be given by the primary care provider consisting of
dietary modication (graded introduction of bre starting with soluble natural bre), aerobic exercise,
Algorithm for Faecal Incontinence
First line measures
History and physical
examination
Investigations if
symptoms persist
Conservative treatment
Salvage procedures
Minimally invasive
therapies
Definitive treatment
Low residue diet and practical advice, sphincter and pelvic floor exercises,
titrated loperamide, psychological support

Exclude luminal causes If change in bowel habit, and investigate
and treat reversible and organic causes and sinister symptoms.
Specifically identify and manage rectal prolapse if present.
Assess sphincter structure with endoanal ultrasound and function with physiology.
Assess pelvic floor trauma, atrophy and fucntion with MRI ( static / dynamic)
Biofeedback, bowel retraining anal
plug, retrograde rectal irrigation.
Bowel program for special groups*
MACE, Artificial bowel sphincter,
dynamic graciloplasty
Stoma
* For the elderly and
neurogenic, consider
Mx of impaction and
incontinence together
Primary overlap repair or redo
repair with non atrophic muscle
Imaging and physiology
informs the algorithm
Isolated IAS defect, intact weak
sphincters, levator atrophy
EAS defect (defect > 90 and <
180) +/- IAS defect
EAS defect > 180 and/
or severe structural injury
Anterior sphincter repair
according to
severity
according to severity
Sacral neuromodulation,
sphincter bulking agents
Fig. 1. Algorithm: faecal incontinence. Abbreviations: IAS internal anal sphincter, EAS external anal sphincter, SNM sacral
neuromodulation, MACE malone antegrade continence enema.
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 615
Intact sphincters IAS defect EAS & IAS defect
Endoanal ultrasound and anorectal physiology
Immediate
repair
Acute Injury
Unrecognised Recognised
Asymptomatic Symptomatic
Asymptomatic
Biofeedback +/- loperamide
Remains symptomatic
Anterior overlap repair
Consider if there
is a repairable
defect or large
persistent defect
post repair
*
*
Asymptomatic Remains symptomatic
Consider sacral nerve stimulation
Asymptomatic
Consider more invasive surgical options
Asymptomatic Remains symptomatic
Stoma
*Invasive Options Include:
ACE Procedure, Bioinjectibles,
SECCA Procedure, Dynamic
Graciloplasty, Artificial Bowel
Sphincter


*
*
Severe perineal trauma
Operative delivery
Suspected 3 tear
Transient symptoms
*
*
Remains symptomatic
Obstetric trauma follow-up protocol
Fig. 2. Algorithm: obstetric trauma.
Algorithm for Constipation
First line measures
History and physical
examination
Special
Investigations
Conservative Tx
Definitive
treatment
Simple measures include dietary modification, exercise,
increase fluid intake, address toileting behaviour
Exclude luminal causes If change in bowel habit,
investigate and treat reversible, organic causes and
sinister symptoms
IBS - C
Sacral
neuromodulation
Colectomy and IRA, ileostomy
Hypnotherapy,
Behavioural
psychotherapy,
CBT, Psychiatrist
Slow transit
Evacuation difficulty Gut dilation
Persisting symptoms
sub divided and
confirmed with Ix
Barium enema, recto -
anal inhibitory reflex, biopsy
Endoscopy /CT if
required
Transit study
Proctography (Ba or MRI)
Pseudo -
obstruction
Megarectum Hirschsprungs
Functional Anatomical
Biofeedback, Behavioural
retraining, Rectal irrigation,
laxatives, prokinetics,
Surgery for rectocele and or
intussusception
Antispasmodics
Tricyclics, SSRIs
Osmotic
laxatives +/-
biofeedback,
suppositories,
enemas
Excision or
bypass of the
aganglionic
segment
Disorder
Specialized
management
Mini invasive Mx
Postural
drainage, Prokinetics,
Cholinesterase
inhibitors, Flatus tube
PEC, endoscopic
decompression
Fig. 3. Algorithm: constipation. Abbreviations: IBS-C irritable bowel constipation predominant, IRA ileorectal anastomosis,
J hypnotherapy, behavioural psychotherapy, CBT, psychiatrist management, CBT cognitive behavioural therapy, Ix investi-
gations, Mx management, Tx treatment.
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 616
uid hydration and regular toileting in the mornings making use of the natural triggers for early
morning bowel emptying (awakening, breakfast, caffeine, and stimulant suppositories to assist).
The stratication into slow transit, evacuation difculties, IBS-C and gut dilation are based on
history taking complimented by appropriate investigations as in the owchart. Patients can be divided
into those with gut dilation (Hirschsprungs, megarectumand pseudo-obstruction) and non-dilated gut
(evacuation disorders, IBS-C and slow transit). Their clinical presentation can be either typical or
atypical. Although patients with Hirschsprungs and megarectum both have faecal impaction, those
with Hirschsprungs seldom have passive leakage, which is frequently seen with patients with meg-
arectum as an overow phenomenon. Hirschsprungs is often treated by excision of the aganglionic
segment. Megarectum can be isolated or coexist with megacolon; both are often managed with
a combination of regular osmotic laxatives such as magnesium salts combined with regular enemas to
avoid impaction. If symptoms are severe, then colectomy and ileorectal anastomosis may be indicated
[9]. Patients with colonic pseudo-obstruction are a difcult group; they too are managed with regular
stimulant laxatives but half of these may also have small bowel involvement. Management is mainly
symptomatic using stimulant laxatives, cholinesterase inhibitors, endoscopic decompression or a PEC
(percutaneous endoscopic colostomy). Some of these patients go on to develop nutritional deciencies
and may require TPN or at its worst intestinal transplant.
Patients with IBS-C typically have constipation symptoms and abdominal pains; treatment is again
symptomatic with antispasmodics, tricyclics, SSRIs and anti epileptic agents that target neuropathic
type pain [10]. Symptoms are often multifactorial and they often require management of behaviour,
stress and emotions. Patients with slow transit often respond to biofeedback in 60%, and sacral neu-
romodulation in approximately 42% [11].
Those with evacuation difculties frequently have coexistent anatomical abnormalities; deciding
whether these abnormalities are best served by surgery is difcult as many will have functional
symptoms (such as pain or the need to strain or anally digitate). The adjunct of proctography is often
helpful informing an overall impression as to whether the abnormality is functionally abnormal
enough to warrant surgery that will be benecial. There is a high degree of sexual abuse in this group of
patients with anismus and in this group it sometimes comprises of a triad of evacuation difculties,
bladder voiding difculties and dispareunia; psychosexual therapy is required here.
Patients may have pelvic organ prolapse symptoms with or without other symptoms of the
prolapsed viscera (anterior compartment bladder, middle compartment uterus or vault and
posterior bowel) (Fig. 4). Often symptoms in all three vaginal compartments need assessment and
treatment in tandem. The algorithm is colour coded for simplicity, but patients may follow multiple
pathways. Fifty percent of parous women will have some degree of pelvic organ prolapse; this
increases with age and parity, with a lifetime risk of operation in 11%, and reoperation in 30% [12].
Bowel dysfunction is also common in 61% of women with uterovaginal prolapse and 30% with urinary
stress incontinence having a history of straining in early adulthood [13]. It is important to realise that
the size of the prolapse does not always correlate with symptoms or function. Patients presenting with
pelvic organ prolapse can have a multitude of symptoms, either directly related to the prolapse
(typically described as heaviness or dull ache in the pelvis worse at the end of the day after prolonged
periods of standing and relieved on lying at), or specic anatomical symptoms of a lump in the vagina,
difculty with intercourse or vaginal laxity. In addition to these symptoms one should always enquire
about the bladder, bowel and sexual function; many of these symptoms are taboo, but are important
and need to be explored tactfully. Initial conservative measures such as weight loss, timed emptying for
both bladder and bowel symptoms, pelvic oor exercises including retraining for incoordination and
strength are helpful. Pessaries (support and space occupying) are available for bladder neck support
and prolapse reduction respectively; it is important to ensure vaginal tissue is healthy and well oes-
trogenized (usually with topical oestrogens) to avoid pessary trauma to an atrophic vaginal epithelium.
When symptoms fail conservative management, further physiological and structural assessment
may be required; these are often organ specic investigations or global assessment investigations such
as the use of static pelvic MRI to assess for levator trauma or atrophy and dynamic MRI to assess all
vaginal compartments for prolapse. Global assessment is important as it may often reveal occult
prolapse in other compartments, which may become more evident after other compartment prolapses
are corrected. The prolapses that develop arise as a result of ligamentous laxity and/or injury of its
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 617
accompanying muscles or muscular atrophy. The procedures developed to correct these address either
closure, excision or closure procedures.
When bladder and bowel symptoms are present in addition to prolapse symptoms, it is important
to differentiate whether the prolapse is causative e.g. bladder voiding difculties with a large cystocele
prolapsing producing kinking of the urethra, or a large rectocele requiring vaginal digitation for
evacuation. Some surgical procedures may worsen pre-existing symptoms e.g. a tension free vaginal
tape for stress urinary incontinence may produce urge urinary incontinence and voiding difculty, and
a transanal rectocele repair may worsen faecal urgency and precipitate incontinence. Therefore before
contemplating surgery, one needs to assess whether it is likely to worsen pre-existing coexisting
symptoms or reveal occult abnormalities; preoperative assessment is imperative.
The algorithm in Fig. 5 describes the detailed assessment and management of chronic pain in
Chapter 10. In the context of chronic pain, it is important to determine the presence of antecedent
factors such as their psychological make up and history of abuse which has a bearing on the back-
ground to developing chronic pain. Secondly identify the precipitating causes such as surgery, trauma
or abuse (psychological, physical or sexual). It is important to exclude organic causes of pain, with
modalities such as endoscopy and cross-sectional imaging; this is also helpful in reassuring patients
that there isnt a sinister cause for their symptoms. The next step is differentiating whether the pain is
specic to one region e.g. anorectal pain, or whether the pain involves multiple regions e.g. those
patients that present with a combination of pelvic pain, migraine, back pain and joint pain. The
management here changes from being region specic to global. Medical management of chronic pain
has evolved with the development of drugs that we currently use to treat depression (tricyclics and
SSRIs) and epilepsy (gabapentin) which also address neuropathic pain. Some agents need specialist
administration and monitoring such as opioid management (now has new forms like transdermal and
sublingual), IV lignocaine, ketamine and cannabinoids. When there are psychological inuences, these
Algorithm for Pelvic floor Prolapse
History and physical
examination
Conservative
treatment
Initial measures
Investigations for on
going symptoms
Surgery
POP with bowel and / or bladder Symptoms
Assess for co-morbidities and oestrogen status.
Examine all 3 vaginal compartments using POP-Q.
Investigate sinister symptoms
Lifestyle changes: Lose weight, pelvic floor exercises, topical oestrogens
and trial of pessary
For OAB (anticholinergics,).
For USI (Duloxetine, PFM
training)
POP without other symptoms
Anterior Posterior Anterior Middle Posterior
Assess structure and function: Bladder (PVR, flow rate, urodynamics), Bowel (anorectal
physiology, endoanal ultrasound), pelvic floor and support (static and dynamic MRI)
Biofeedback for
incontinence & emptying
difficulties. Rectal
irrigation. SNM.
1. Consider anatomical support with space occupying or
rigid support pessaries.
2. Topical oestrogens .
OAB Botulinum
toxin, SNM,
cystoplasty
SUI Suspension
procedures (TVT or
colposuspension)
Voiding difficulties
assess further
Rectal prolapse consider
perineal or abdominal
procedures. For
evacuation difficulties and
a prevailing anatomical
abnormality consider
rectal approach
if emptying difficulties,
perineal if vaginal
digitation helps
1. Anterior/Posterior prolapse
anterior/posterior vaginal repair.
2. Triple compartment prolapse:
-Suspension procedures - (Hysteropexy,
sacrocolpopexy, sacrospinous fixation)
-Closure procedures - colpocleisis,
culdoplasty
-Vaginal hysterectomy
Prolapse, bowel and bladder
symptoms may need synchronous
management
Fig. 4. Algorithm: pelvic organ prolapse. Abbreviations: POP-Q: pelvic organ prolapse quantication system, PVR post-void
residual, OAB overactive bladder, PFM pelvic oor muscle, SNM sacral neuromodulation, TVT tension free vaginal tape, USI
urodynamic stress incontinence, MRI magnetic resonance imaging. Acknowledgements to Mrs. Sohier Elneil and Mr. Arvind
Vashist, Department of Urogynaecology at University College Hospital for their input in this algorithm.
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 618
too need to be managed in parallel with the use of drugs. Psychological treatment can vary in its
intensity and form. Like drugs, there are several therapies available such as behavioural management,
psychodynamic therapy, hypnotherapy, and counselling. Some patients need to be referred to
specialists for a more invasive approach targeting the peripheral symptoms e.g. the use of pudendal
nerve blocks for pelvic pain and Botulinum toxin injections for levator ani spasticity. Invasive surgery
for chronic pain in the endorgan has frequently had a poor outcome possibly as a result of central
sensitisation and it has a limited role. More recently there have been several case reports reporting the
use of sacral neuromodulation for treating complex regional pain syndromes; further studies are
awaited [14].
Conclusion
The management of complex pelvic oor disorders should not be a singular endeavour in the
current era of the MDT. The recipe for this to work depends on the expertise involved and most
importantly the willingness for specialities to communicate and encourage healthy debate.
Algorithm for Pelvic Pain
History and physical
examination
Mini invasive
Refer to a pain MDT
Surgery / Definitive
Management
Investigate sinister symptoms, exclude organic causes, but beware of over
testing. Assess triggers, predisposing and maintenance factors. Assess
premorbid psychological issues, sexual abuse. Assess postmorbid non pain
symptoms, psychology, behavioural, sexual and social factors
Chronic pelvic pain syndrome
Determine
subclassification
First line measures
Region specific
Anorectal Uterine Bladder
Analgesic ladder, tricyclics, SSRIs, gabapentin, pregabalin, benzodiazepines
Consider Na channel blockers (IV
lignocaine), NMDA antagonists
(ketamine), cannabinoids, opiates
Physiotherapy (triggerpoint/postural/stretching)
Nerve blocks (e.g. pudendal), LA into trigger points,
Botlinum toxin into spastic muscles
Consider CBT (psychological
management of negative mood and
cognition, physiotherapy management
of negative behavior), psychodynamic
therapy, psychosexual counseling, or a
psychiatrist in tandem with drugs
Surgery and neuromodulation in specialist centres
Fig. 5. Algorithm: chronic pelvic pain. Abbreviations: NMDA N-methyl-D-aspartate, SSRI selective serotonin re-uptake inhibitors,
MDT multidisciplinary team, IV intravenous, LA local anaesthetic. Acknowledgement to Dr. Andrew Baranowski, Consultant in
Urogenital Pain Medicine, University College Hospital for his input in this algorithm.
Practice points
Multidisciplinary working is the denitive approach to managing patients with pelvic oor
dysfunction, both to identify optimal care and avoid over-investigation.
The meeting of minds should have at its core evidence based practice, encouraging research
and audit to improve outcome.
Specialised investigations should be standardised according to local expertise.
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 619
References
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Research agenda
The value of each component of the algorithm needs to be established, for example:
Faecal incontinence: at what stage should anorectal physiology tests be performed, and do
they inuence outcome?
Faecal incontinence and evacuation difculty: should retrograde transanal irrigation be
offered to non-neurologically injured patients as an alternative to biofeedback?
Post-obstetric pelvic oor trauma: how should information about structure and function in
this patient group inform management of subsequent deliveries?
Chronic pelvic pain: do we focus on interventions treating central factors or peripheral ones,
or both?
D. Chatoor et al. / Best Practice & Research Clinical Gastroenterology 23 (2009) 611620 620