Pelvic Floor Dysfunction

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Pelvic Floor Dysfunction

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G. Willy Davila, Gamal M. Ghoniem and Steven D. Wexner (Eds.)

Pelvic Floor Dysfunction

A Multidisciplinary Approach

With 178 Figures

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G. Willy Davila, MD Gamal M. Ghoniem, MD, FACS Chairman, Department Head, Section of Voiding Dysfunction,

of Gynecology; Head, Section Female Urology and Reconstruction of Urogynecology and Clinical Professor of Surgery/Urology, Reconstructive Pelvic Surgery NOVA Southeastern University Cleveland Clinic Florida Ohio State University and University of

Weston, FL, USA South Florida

Afﬁliate Associate Professor, University Cleveland Clinic Florida

of South Florida, USA Weston, FL, USA

Steven D. Wexner, MD, FACS, FRCS, FRCSED Chief of Staff, Cleveland Clinic Hospital 21st Century Oncology Chair in Colorectal

Surgery

Chairman, Department of Colorectal Surgery Cleveland Clinic Florida

Professor of Surgery, Ohio State University Health Sciences Center at Cleveland Clinic Foundation

Clinical Professor of Surgery, University of South Florida College of Medicine Research Professor, Charles E. Schmidt

College at Florida Atlantic University

A Catalogue record for this book is available from the British Library.

Library of Congress Control Number: 2005924370 ISBN-10: 1-85233-730-3 Printed on acid-free paper ISBN-13: 978-1-85233-730-8

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I dedicate this work to those who have been instrumental in the development of my urogynecologic career: Dr. Donald Ostergard for teaching me the basics and beyond, Dr.

Oscar Contreras Ortiz for encouraging me to become involved, and Dr. Harold Drutz for showing me how to achieve “the balance.” To these mentors and friends I am forever in debt, and no words can express my appreciation for their warmth and interest in my pro- fessional and personal growth. I attempt to emulate their efforts on a daily basis.

G. Willy Davila, MD

My work on this book is dedicated to the memory of the great men who inﬂuenced my life’s work, and who passed in December 2003. To the memory of my father, Mostafa Ghoniem and my mentor, Mohamed Al-Ghorab, to whom I will be eternally grateful for their love and support.

Gamal Ghoniem, MD

This book is dedicated to the most important people in my life – my family. To my parents, for having taught me by their example to succeed by hard work, honesty, and perseverance. Their love and guidance made it possible for me to have achieved my career. To my wife Nicolette, whose devotion to me and to our children and whose intel- lectual stimulation and love have made it possible for me to continue to be productive and innovative. To my children Wesley, Trevor, Marisa, and Gabriella, as it was precious time away from them that allowed me to produce these pages.

Steven D. Wexner, MD

The editors and authors express their gratitude to Ms. Kristin Dunn and Ms. Stacy Kopka for their exhaustive efforts in preparation of the manuscripts for publication; and Ross Papalardo and Beth Halasz for their superb medical illustration skills.

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Foreword

All the characteristics and driving force of The Cleveland Clinic are to be found in this book on pelvic ﬂoor function. The Cleveland Clinic is a group practice founded in 1921 on the principles of cooperation, collaboration, and collegiality. Its founders believed that many physicians working together will discover better solutions to medical problems than physicians working in isolation. They believed that the combination of disciplines, with their inherent differences in philosophy and skills, will produce a better outcome than might have evolved singularly.

The power of the collaborative approach is on full display in this book. The pelvic floor unites three separate organ systems. Before this time, each has been approached individually. Urologists, gynecologists, and colorectal surgeons are each trained in their own disciplines, and the pelvic floor is subsumed in these larger fields of study. When they combine their focus on the pelvic floor, they bring their unique perspectives and different approaches to a common goal: the relief of pelvic floor syndromes such as incontinence and pelvic organ prolapse.

The notion that three disciplines can combine for a better outcome than they would achieve singly, is a modern-day version of an old fable. The American poet John Godfrey Saxe (1816–1887) adapted that fable in his poem, “The Blind Men and the Elephant.” It tells the story of six blind wise men who encounter an elephant for the first time, and how they try to make sense of it by touch alone. The first blind man falls against the side of the elephant, and declares that the elephant is like a wall. The second man feels the tusk and concludes that anything so sharp is like a spear. The third man grabs the trunk and announces that the elephant is like a snake. The fourth man feels the knee and states that the elephant is like a tree. The fifth blind man touches the ear and decides that it is like a fan. The six man grabs the tail and decides it is a like a rope. Each wise man feels the elephant from his own small perspective and visualizes something different. As indi- viduals, they think they have the answer. But if they had combined their impressions, they would have reached a far different conclusion.

The practice of joining with colleagues to visualize a problem from your own perspective and the group perspective, can lead to magnificent conclusions and interesting solutions. That is precisely what happens in this book. By combining the views of three different disciplines, which have furthered our knowledge of pelvic floor function, it offers a new and better approach to dysfunction. Medicine has advanced tremendously in the past half century, more specifically in the past two decades. The dominance of traditional specialties such as urology, gynecology, and general surgery has given way to an emphasis on subspecialties such as urogynecology, female urology, and colorectal surgery. This has allowed experts, such as the authors, to focus on a narrower field, and enjoy greater success than they might have if their concentration had been diluted by many broad interests. In this book, they are the personification of teamwork. Their characteristics of focus, innovation, collaboration, and dedication are the very qualities that will someday advance medicine far beyond anything we can imagine today.

By combining their expertise in this book, the authors have made a tremendous advance in the understanding of the pelvic ﬂoor and its dysfunction. They have raised vii

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viii Foreword

medicine to yet a higher level, and performed a service that will beneﬁt patients with pelvic ﬂoor dysfunction for years to come.

Robert Kay, MD Vice Chairman, Board of Governors Chief of Staff The Cleveland Clinic Foundation Cleveland OH, USA

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Introduction

The aging of our population and arrival of the baby-boomers to advanced adulthood, with expectations for high quality of life, have led to a greater public awareness and help- seeking behavior regarding symptomatic dysfunction of the organs found within the pelvic cavity in women, the female pelvic floor. Women are increasingly less willing to simply accept incontinence or prolapse as a normal part of the aging process. New tech- nologies and a greater understanding of the pathophysiology underlying these dys- functions have provided us with a number of effective tools for treatment of these patients. Unfortunately, the traditional fragmentation of health care duties among spe- cialists has led to significant gaps in the treatment of pelvic floor dysfunction. The concept of the female pelvic floor as a single functional unit has not yet gained wide acceptance. Importantly, postgraduate training programs have not adapted their cur- ricula to meet the growing need to produce clinicians with an expertise in the management of the various aspects of pelvic floor dysfunction. Thus, there is not a sole clinician who can care for all of the problems that can develop within the pelvic floor. Under our current medical care environment, a multidisciplinary team approach will best serve the needs of symptomatic women. The need for such a team is gaining increasing degrees of acceptance at referral centers. Unfortunately, multiple barriers are in place to prevent such teams from forming and functioning efficiently.

There are currently efforts around the world to delineate training requirements for certiﬁcation in Urogynecology/Female Pelvic Medicine/Reconstructive Pelvic Surgery (after training in Obstetrics and Gynecology) and Female Urology (after training in Urology). Colorectal surgeons and gastroenterologists have long had an interest in anatomic and functional problems of the lower intestinal tract. Nevertheless, clinicians caring for adjacent pelvic organ systems have yet to achieve a consensus regarding the importance and value of the evaluation and management of pelvic ﬂoor problems exis- tent on either side of an anatomic system. As a result, patients may undergo sequential operative procedures and/or achieve only limited quality-of-life improvement with therapy.

Realizing the above shortcomings and the frequent coexistence of pelvic ﬂoor dysfunction symptoms among many patients referred for care, the Cleveland Clinic, at its various campuses, has developed a team approach to the care of such patients. Either within one Pelvic Floor Center, such as at our Fort Lauderdale/Weston, Florida campus or in very close proximity, such as in our Naples, Florida or Cleveland, Ohio campuses, patients are evaluated and treated by a team of clinicians with expertise in the various aspects of symptomatic dysfunction. After coordination of evaluation procedures, a treatment plan is designed. Whether care involves a combined surgical procedure or medical intervention, a patient’s medical care is streamlined and patients beneﬁt from a global quality-of-life improvement. This text represents a compilation of the clinical approaches of the staff at Cleveland Clinic in the management of disorders involving the lower urinary, genital, and intestinal tracts. It should be a valuable reference for all clinicians involved in the care of women with symptomatic dysfunction of these systems.

It will be apparent to clinicians from various ﬁelds that there are remarkable similari- ties and analogies in terms of presenting symptoms, evaluation modalities, and treatment approaches. It is the hope of the authors that clinicians will begin to see the various organ systems as part of a combined unit. As such, recognizing the presence of symp- ix

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x Introduction

toms involving adjacent organ systems will encourage clinicians to recruit and involve other clinicians with expertise in addressing such symptoms in order to optimize the medical care being provided to a symptomatic patient. Our experience has demonstrated that improvements in quality of life and patient satisfaction can be greater when a com- prehensive, horizontally integrated approach is utilized, and we look forward to other centers adopting our model and philosophy of patient care.

G. Willy Davila, MD

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Contributors

George Abate, DO

Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Joseph Abdelmalak, MD

Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA

Matthew D. Barber, MD, MHS Section of Urogynecology and

Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Daniel H. Biller MD

Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Gynecology,

Cleveland Clinic Florida, Weston, FL, USA

Gregory F. Bonner, MD

Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL, USA

Susan M. Cera, MD

Department of Colorectal Surgery, The Cleveland Clinic Foundation, Weston, FL, USA

Firouz Daneshgari, MD

Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA

Giovanna M. DaSilva, MD

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA

G. Willy Davila, MD

Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA James Doty, MD

Department of Colorectal Surgery, Cleveland Clinic Florida, Naples, FL, USA

Jonathan E. Efron, MD, FACS, FASCRS Department of Colorectal Surgery,

Cleveland Clinic Florida, Naples, FL, USA

Ahmed Elazab, MD

Lawrence P. Frank, MD

Department of Anesthesiology, Cleveland Clinic Florida, Weston, FL, USA Tara L. Frenkl, MD, MPH

Gamal M. Ghoniem, MD, FACS

Section of Voiding Dysfunction, Female Urology and Reconstruction,

Department of Urology, Cleveland Clinic Florida, Weston, FL, USA Wagih W. Gobrial, MD

Section of Head Pain Management, Division of Anesthesiology, Cleveland Clinic Florida, Weston, FL, USA Nathan Guerette, MD

Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA

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xviii Contributors

Gassan Haddad, MD

Department of Internal Medicine, Cleveland Clinic Florida, Weston, FL, USA

John C. Hairston, MD

Section of Female Urology, Voiding Dysfunction and Pelvic

Reconstruction, Cleveland Clinic Florida, Department of Urology, Weston, FL, USA

Lawrence S. Hakim, MD, FACS Section of Sexual Medicine, Infertility

and Prosthetics, Department of Urology, Cleveland Clinic Florida, Weston, FL, USA

Tracy L. Hull, MD

Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA

Jonathan Jay, MD, FACS

Department of Urology, Cleveland Clinic Florida, Naples, FL, USA, USA Robert Kay, MD

Vice Chairman, Board of Governors, Chief of Staff, The Cleveland Clinic Foundation, Cleveland, OH, USA Usama M. Khater, MD

M. Louis Moy, MD

Minda Neimark, MD

Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA Juan J. Nogueras, MD

Marie Fidela R. Paraiso, MD Department of Obstetrics and

Gynecology, Urological Institute and Women’s Health Center, Section of Urogynecology and Reconstructive Pelvic Surgery, The Cleveland Clinic Foundation, Cleveland, OH,

USA

Benjamin Person, MD

Ronnie R. Pimentel, MD, FACP, FACG Department of Gastroenterology,

Jennifer T. Pollak, MD

Florida Center for Urogynecology, Hollywood, FL, USA

Raymond R. Rackley, MD

Virgilio Salanga, MD, MS Department of Neurology,

Dana R. Sands, MD

T. Cristina Sardinha, MD

Andrew I. Sokol, MD

Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA

Wael Solh, MD

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Contributors xix Kevin J. Stepp, MD

Section of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Joanna M. Togami, MD

Sandip P. Vasavada, MD

Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA Dawn Vickers, RN

Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL, USA

Mark D. Walters, MD

Section of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, The Cleveland Clinic Foundation, Cleveland, OH, USA Eric G. Weiss, MD

Steven D. Wexner, MD, FACS, FRCS, FRCSED

Samir M. Yebara, MD

Pelvic Floor Dysfunction

Pelvic Floor Dysfunction

G. Willy Davila, Gamal M. Ghoniem and Steven D. Wexner (Eds.)

Pelvic Floor Dysfunction

A Multidisciplinary Approach

Foreword

Introduction

Contents

Contributors