WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.
Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York. A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.
Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation. “However, these problems have tremendous psychosocial implications for older women,” Dr. Gurland said. And failure to identify pelvic floor pathology can lead to treatment failure and frustration for both doctors and patients.
Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.
To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.
The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.
Plans so far have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.
“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.
The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”
In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients. “Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland said. “We can also see the postops together and see how people are responding to treatment.”
Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and includes incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.
Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation. The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.
Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure. Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.
An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.
Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.