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Pelvic Floor Disorders
Pelvic floor and functional bowel disorders refer to a series of symptoms and anatomic findings that are not life threatening but can be life altering. These disorders are associated with significant economic burden due to loss of work, disability, and disjointed care across several subspecialties. Approximately one-quarter of all women suffer from at least one pelvic floor disorder in their lifetime. Pelvic organ prolapse has an estimated prevalence of 3 to 8%, and 20% of women undergo stress urinary incontinence or prolapse repair surgery by the age of 80. As the aging population grows, the number of women with pelvic floor dysfunction will increase substantially and the demand for care of these disorders will continue to grow. Furthermore, patients undergoing surgery for rectal cancer, inflammatory bowel disease, rectal prolapse, prostate cancer, pelvic radiation, and trauma may suffer from a myriad of subsequent functional disorders. These disorders will significantly affect their quality of life long after their life-threatening disease has been treated.
In the last decade, there has been a tremendous increase in new technologies, new surgical techniques, and new imaging modalities that impact the care of patients with pelvic floor disorders. Subsequently, the treatment pathways for common disorders such as constipation, prolapse, and incontinence have changed drastically. And the need to work across subspecialties in a multidisciplinary fashion is crucial. The goal of this issue is to highlight changes in treatment pathways, pelvic floor testing techniques, surgical approaches, and collaboration with other pelvic floor specialists.
Collaborating with other medical and surgical specialties to optimize patient care and collect meaningful data requires a common language and common set of assessment tools. Drs. Bordeianou, Calvallaro, and Hunt review the metrics used to assess pelvic floor patients and introduce the IMPACT assessment tool that can facilitate multispecialty collaboration. Drs. Kwakye and Maguire provide an updated approach to the use of anorectal physiology testing and how this has changed with the introduction of newer surgical techniques.
Treatment options for patients plagued with fecal incontinence and urgency continue to evolve and grow. The introduction of sacral neuromodulation in the United States in 2011 sparked major changes in the evaluation and treatment algorithm for these patients. Dr. Bhullar and Dr. Katuwal review the stages of sacral neuromodulation, plus this therapy's advantages and pitfalls. Drs. Ivatury, Paquette, and Wilson discuss new alternatives in the treatment of fecal incontinence and show how these options are incorporated into a care pathway. Dr. Jensen and Dr. Dawes review the management of rectovaginal fistulas which continues to be a frustrating challenge for patients and surgeons.
Some of the most novel changes in treatment algorithms and surgical collaboration are seen in the area of pelvic organ prolapse. New techniques, such as ventral rectopexy and combined posterior and middle pelvic compartment repairs, have generated scrutiny as to how patients are evaluated, tested, and treated to optimize outcomes, reduce recurrence, and avoid inappropriate surgery. Differentiating between outlet obstruction caused by prolapse versus poor muscle coordination is critical. Dr. Simianu and Dr. Kaplan highlight the importance of this distinction and discuss the use of Botox for pelvic dyssynergia. Dr. Curran and Dr. Hite highlight the importance of pelvic floor coordination and the use of biofeedback. The surgical considerations and technique for ventral rectopexy are reviewed by Dr. Loh and Dr. Umanskiy. Finally, the importance of multidisciplinary collaboration in treating patients with pelvic floor disorders and prolapse is discussed by Dr. Gurland and Dr. Mishra.
I would like to thank all of these talented authors for their extraordinary work and personal commitment to this challenging topic. It is a privilege to have them all as friends and colleagues. I would also like to thank Dr. Scott Steele for giving me the opportunity to be the guest editor for this issue, and for his endless enthusiasm to stay at the forefront of excellence in the field of colorectal surgery. I truly appreciate his leadership, mentorship, and support.
04 November 2020 (online)
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