Pelvic Floor Disorders (eBook)

Title Page 
3 
Copyright Page 
4 
Foreword 7
Foreword 8
Foreword 10
Preface 11
Table of Contents 
13 
Contributors 21
Section I Pelvic Floor Anatomy 
28 
1 State of the Art Pelvic Floor Anatomy 
29 
1.1 Introduction 29
1.1.1 Support of the Pelvic Organs: Conceptual Overview 
29 
1.2 Functional Anatomy and Prolapse 31
1.2.1 Overview 31
1.2.2 Apical Segment 32
1.2.3 Anterior Compartment 33
1.2.4 Perineal Membrane(Urogenital Diaphragm) 36
1.2.5 Posterior Compartment and Perineal Membrane 
36 
1.2.6 Lateral Compartment and Levator Ani Muscles 
38 
1.2.7 Endopelvic Fascia and Levator Ani Interactions 
40 
1.2.8 Nerves 40
References 40
2 The Integral Theory: A Musculo-elastic Theory of Pelvic Floor Function and Dysfunction 
42 
2.1 Introduction 42
2.1.1 Origins and Development of the Integral Theory 
42 
2.2 Function 43
2.2.1 The Organs 43
2.2.2 The Ligaments 43
2.2.3 The Muscles 43
2.2.4 The Nerves 43
2.2.5 Role of Urethral Resistance Incontinence Control 
44 
2.2.6 Role of Urethral Resistance in Organ Evacuation 
44 
2.2.7 Anorectal Function and Dysfunction 
45 
2.3 Dysfunction: Causation of Lax Connective Tissue 
45 
2.4 Diagnosis 45
2.4.1 Diagnosis of Damaged Ligaments (by Symptoms) 
45 
2.4.2 Diagnosis of Damaged Ligaments (by Vaginal Examination) 
47 
2.4.2.1 “Simulated Operations” 47
2.5 Management: Surgery 47
2.6 Conclusions 47
References 48
3 Pathophysiology of the Pelvic Floor: Basic Physiology, Effects of Ageing, and Menopausal Changes 
49 
3.1 Introduction 49
3.2 Connective Tissue Supports and the Vaginal Wall 
50 
3.2.1 Collagen 50
3.2.2 Elastin 50
3.2.3 Smooth Muscle 51
3.2.4 Challenges 51
3.3 Levator Ani Muscles 51
3.3.1 Challenges 51
3.4 Nerves 51
3.5 Vaginal Birth 52
3.6 Hormones, Menopause, and Ageing 52
3.6.1 Tissue Factors and Mechanisms of Action 
53 
3.6.2 Hormone Use and Prevention of POP 
53 
3.6.3 Urinary Incontinence 54
3.6.3.1 Tissue Factors and Mechanisms of Action 54
3.7 Conclusions 54
References 55
4 The Pelvic Floor: Functional Concepts and Neurocontrol 
57 
4.1 Introduction 57
4.2 The Pelvic Floor 58
4.3 Functional Abnormalities in Idiopathic Fecal Incontinence 
58 
4.3.1 Clinical Issues 59
4.3.2 Anorectal Pressure Measurements 59
4.3.3 Muscle Biopsies 59
4.3.4 Electromyographic Evidence 60
4.3.5 Pudendal Nerve Terminal Motor Latency Measurements 
60 
4.4 Stress Urinary Incontinence 60
4.5 Childbirth and the Pelvic Floor 61
4.6 Other Factors Leading to “Idiopathic” Fecal Incontinence 
61 
4.7 Central Control Mechanisms of the Pelvic Floor 
62 
4.7.1 Physiological Principles of Motor Control 
62 
4.7.2 The Brain and Spinal Cord 63
4.8 Feedback Modulation Therapy 64
4.9 Conclusions 64
References 64
5 Clinical Neurophysiology of the Pelvic Floor 
67 
5.1 Introduction 67
5.2 Neuroanatomy 68
5.3 Role of Neurophysiologic Studies 68
5.4 Types of Neurophysiologic Studies 69
5.4.1 Nerve Conduction Studies 69
5.4.1.1 Stimulating 69
5.4.1.2 Recording 69
5.4.1.3 Compound Muscle Action Potential 69
5.4.1.4 Pudendal Nerve Terminal Motor Latency 70
5.4.1.5 Perineal Nerve Conduction Studies 71
5.4.1.6 Sacral Reflexes 72
5.4.2 Electromyography 73
5.4.2.1 Kinesiologic EMG 73
5.4.2.2 Needle EMG 73
5.4.2.3 The Anal Sphincter 74
5.4.2.4 The Striated Urethral Sphincter 75
5.4.2.5 The Levator Ani 76
5.5 Clinical Applications 76
5.5.1 Fecal Incontinence 76
5.5.2 Urinary Incontinence 76
5.5.3 Pelvic Organs Prolapse 77
5.5.4 Post-operative Assessment 77
5.5.5 Childbirth 77
5.5.6 Neurologic Conditions 78
5.6 Conclusions 78
References 78
Section II Pelvic Floor Imaging 
80 
Pelvic Floor Imaging: Introduction 
81 
References 82
6 Endovaginal Ultrasonography:Methodology and Normal Pelvic Floor Anatomy 
83 
6.1 Introduction 83
6.2 Technical Aspects of 3D Endovaginal Ultrasound 
84 
6.3 3D Ultrasonographic Anatomy of the Pelvic Floor 
88 
6.3.1 Assessment of the Anterior Compartment 
91 
6.3.2 Assessment of the Lateral Compartment 
94 
6.3.3 Assessment of the Posterior Compartment 
95 
6.4 Discussion 97
References 99
7 Translabial Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 
101 
7.1 Introduction 101
7.2 Methodology and Instrumentation 102
7.2.1 Two-dimensional Imaging 102
7.2.2 Three-dimensional Imaging 103
7.2.3 Display Modes 104
7.2.4 Four-dimensional Imaging 104
7.3 Functional Assessment 105
7.3.1 Valsalva Maneuver 105
7.3.2 Pelvic Floor Muscle Contraction 107
References 110
8 Endoanal and Endorectal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 
112 
8.1 Introduction 112
8.2 Ultrasonographic Technique 112
8.3 Endosonographic Anatomy of the Anal Canal 
114 
8.4 Endosonographic Anatomy of the Rectum 
118 
8.5 Normal Values 119
References 122
9 Technical Innovations in Pelvic Floor Ultrasonography 
124 
9.1 Introduction 124
9.2 Volume Render Mode 125
9.3 Maximum Intensity Projection 126
9.4 Brush Options – Segmentation –Sculpting 127
9.5 Fusion Imaging 128
9.6 PixelFlux 130
9.7 Framing 132
9.8 Motion Tracking and Color Vector Mapping 
133 
References 135
Invited Commentary 136
10 Magnetic Resonance Imaging: Methodology and Normal Pelvic Floor Anatomy 
138 
10.1 Introduction 138
10.2 The Urethra 138
10.3 Urethral Support 139
10.4 Uterine and Vaginal Support 140
10.5 The Perineal Body 140
10.6 The Anal Sphincter 140
10.6.1 The Internal Anal Sphincter 141
10.6.2 The Intersphincteric Space and Longitudinal Layer 
141 
10.6.3 The Outer Striated Layer: External Anal Sphincter 
141 
10.6.4 The Outer Striated Layer: Puborectal Muscle 
142 
10.7 Anal Sphincter Support 142
10.8 The Rectum and Rectal Support 142
10.9 The Pelvic Floor 143
10.9.1 The Perineal Membrane (Urogenital Diaphragm) 
143 
10.9.2 The Pelvic Diaphragm 143
10.10 The Levator Ani Muscle 143
10.11 The Coccygeus Muscle 144
References 144
11 Technical Innovations in Magnetic Resonance Imaging of the Pelvic Floor 
145 
11.1 Introduction 145
11.2 Static Magnetic Resonance Imaging 
145 
11.3 Dynamic Magnetic Resonance Imaging 
146 
11.4 Patient Positioning 146
11.5 Patient Preparation 147
11.6 Imaging Technique 147
11.7 Image Analysis 148
11.8 Conclusions 149
References 150
Invited Commentary 151
References 152
Section III Pelvic Floor Damage Due to Childbirth 
153 
Pelvic Floor Damage Due to Childbirth: Introduction 
154 
12 Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 
155 
12.1 Introduction 155
12.2 Pelvic Organ Prolapse 155
12.3 Urinary Incontinence 156
12.4 Pelvic Floor Damage 156
12.5 Damage to the Pelvic Floor Nerve Supply 
157 
12.6 Damage to the Endopelvic Fascia 158
12.7 Vascular Damage 158
12.8 Anal Sphincter Injury 158
12.9 Chronic Pelvic Pain 158
12.10 Episiotomy 158
12.11 Cesarean Section 158
12.12 Conclusions 159
References 159
13 Posterior Compartment Disorders and Management of Acute Anal Sphincter Trauma 
160 
13.1 Introduction 160
13.2 Rectoceles 160
13.3 Obstetric Anal Sphincter Injuries (OASIS) 
161 
13.3.1 Applied Anatomy and Physiology 161
13.3.2 Diagnosis of OASIS 162
13.3.3 Repair of OASIS 162
13.3.4 Timing of Repair 163
13.3.5 Technique of Repair 164
13.3.6 Suture Material 165
13.3.7 Role of Antibiotics 166
13.3.8 Stool Softeners 166
13.3.9 Postoperative Catheterization 166
13.3.10 Postoperative Analgesia 166
13.3.11 Follow-up 166
13.3.12 Management of Subsequent Pregnancies 
166 
13.3.13 Training Issues 168
13.4 Conclusions 169
References 169
14 Prevention of Perineal Trauma 
171 
14.1 Introduction 171
14.2 Interventions with Evidence from Randomized Controlled Trials 
172 
14.2.1 Antenatal Perineal Massage 172
14.2.2 Water Birth 172
14.2.3 Position During Labour and Birth 172
14.2.4 Second-stage Pushing Advice 173
14.2.5 Application of Obstetric Gel in the Second Stage of Labor 
173 
14.2.6 Application of Perineal Warm Packs in the Second Stage of Labor 
173 
14.2.7 Perineal Support 174
14.2.8 Second-stage Perineal Massage 174
14.2.9 Episiotomy 174
14.2.10 Instrumental Delivery 175
14.3 Proposed Techniques to Reduce Perineal Trauma 
176 
14.3.1 Antenatal Pelvic Floor Muscle Training 176
14.3.2 Epidural Analgesia 176
14.3.3 Head Flexion 176
14.3.4 Active Restraint of Delivery of the Head 
176 
14.3.5 Delivery of the Shoulders 176
14.3.6 Interventions to Correct or Deliver with an Occipito-posterior Position 
177 
14.4 Conclusions 177
References 177
Invited Commentary 179
Invited Commentary 181
References 182
Section IV Urinary Incontinence and Voiding Dysfunction 
183 
Urinary Incontinence and Voiding Dysfunction: Introduction 
184 
Age 184
Race 185
Pregnancy and Childbirth 185
Mode of Delivery 186
Obesity 186
Classification and Diagnosis of Urinary Incontinence 
186 
References 188
15 Ultrasonography 
189 
15.1 Introduction 189
15.2 External Ultrasound 190
15.2.1 Examination Technique 191
15.3 Endoluminal Ultrasound 192
15.3.1 Examination Technique 193
15.4 Discussion 194
References 199
Invited Commentary 202
16 Urodynamics 
203 
16.1 Introduction 203
16.2 Uroflowmetry 203
16.3 Cystometry and Pressure-Flow Study 
205 
16.4 Electromyography 212
16.5 Video-urodynamics 213
16.6 Urethral Pressure Profilometry 215
16.7 Valsalva Leak Point Pressure Test 216
16.8 Conclusions 216
References 217
Invited Commentary 218
References 220
17 Tape Positioning 
221 
17.1 Theoretical Background of Midurethral Tape Action 
221 
17.2 How Does the Midurethral Tape Work? 
222 
17.3 Does the Tape Position Affect Treatment Outcome? 
223 
17.4 Tape Position and Postoperative Complications 
224 
17.5 Techniques of Tape Positioning 225
References 226
18 Selection of Midurethral Slings for Women with Stress Urinary Incontinence 
228 
18.1 Introduction 228
18.2 Other Types of Retropubic Midurethral Slings 
229 
18.2.1 The Suprapubic Arch Sling (SPARC) 229
18.2.2 Intravaginal Slingplasty (IVS) 229
18.2.3 Self-made Slings 230
18.2.4 Overview 230
18.3 Other Approaches for Sling Placement 
230 
18.3.1 The Transobturator Route 230
18.3.2 Outside-in versus Inside-out 230
18.3.3 Retropubic Versus Obturator 231
18.4 Predictors of Failure 231
18.4.1 Intrinsic Sphincter Deficiency 233
18.4.2 Effect of MUS on Lower Urinary Tract Function 
233 
18.4.3 The Elderly 235
18.4.4 The Obese 237
18.5 Biological Slings and Exitless Slings 
237 
18.5.1 Exitless Mini-sling 238
18.6 Surgeon-related Factors 238
18.7 Summary 238
18.8 Conclusions 239
References 239
19 Injectable Biomaterials 
244 
19.1 Introduction 244
19.2 Injectable Biomaterials 244
19.3 Safety 246
19.4 Injection Technique 247
19.5 Cost 247
19.6 Efficacy 248
19.7 Conclusions 248
References 248
20 Artificial Urinary Sphincter in Women 
250 
20.1 Introduction 250
20.2 Artificial Urinary Sphincter 250
20.2.1 Inflatable Cuff 250
20.2.2 Pressure-regulating Balloon Reservoir 
250 
20.2.3 Control Pump 251
20.2.4 Connecting Tubing 251
20.2.5 Indications 251
20.2.6 Contraindications 252
20.3 Operation 252
20.3.1 Preoperative Counseling and Preparation 
252 
20.3.2 Open Procedure for Insertion of AUS 
252 
20.3.2.1 Abdominal Approach 252
20.3.2.2 Vaginal Approach 252
20.3.2.3 Laparoscopic Extraperitoneal Approach 252
20.4 Complications 255
20.4.1 Perioperative Complications 255
20.4.1.1 Injury During Trocar Placement 255
20.4.2 Early Postoperative Complications 255
20.4.2.1 Urinary Retention 255
20.4.2.2 Infection and Extrusion of the Prosthesis 255
20.4.3 Late Postoperative Complications 255
20.4.3.1 Urethral Atrophy, Erosion or Extrusion 
255 
20.4.3.2 Mechanical Failure 256
20.4.3.3 Recurrent/Persistent Urinary Incontinence 
256 
20.5 Brief Review of the Literature on AUS Implantation in Women 
256 
20.5.1 Open Procedure 256
20.5.2 Laparoscopic Procedure 256
20.6 Conclusions 257
References 257
21 Sacral Nerve Stimulation 
258 
21.1 Historical Overview 258
21.2 Mode of Action 259
21.3 Indications 259
21.4 Selection Criteria 259
21.5 Implant Technique 260
21.6 Results 260
21.7 Complications 260
21.8 Conclusions 261
References 261
Invited Commentary 262
22 Biofeedback 
264 
22.1 Introduction 264
22.2 Purpose of Using Biofeedback 265
22.3 Effect of Biofeedback Training 266
22.4 Clinical Recommendationsfor the Use of Biofeedback 278
References 278
23 Medical Treatment of Urinary Incontinence, Urinary Retention, and Overactive Bladder 
280 
23.1 Introduction 280
23.2 Types of Urinary Incontinence 281
23.3 Pharmacotherapy 281
23.3.1 Pharmacotherapy of Urge Urinary Incontinence and Overactive Bladder 
282 
23.3.2 Pharmacotherapy of Stress Urinary Incontinence 
283 
23.3.3 Pharmacotherapy in Patients with Chronic Retention of Urine with and without Urinary Incontinence 
284 
23.4 Conclusions 285
References 285
Invited Commentary 286
Section V Fecal Incontinence 
287 
Fecal Incontinence: Introduction 
288 
References 290
24 Three-dimensional Endoluminal Ultrasonography 
292 
24.1 Introduction 292
24.2 Internal Anal Sphincter Abnormalities 
293 
24.3 External Anal Sphincter Abnormalities 
294 
24.4 Puborectalis Muscle Abnormalities 
299 
24.5 Accuracy and Reliability 299
24.6 EAUS versus MRI 301
References 302
25 Transperineal Ultrasonography 
304 
25.1 Introduction 304
25.2 Perineal Ultrasonography 305
25.2.1 The Technique of Transverse External Sonography 
305 
25.2.2 The Technique of Sagittal External Sonography 
306 
25.2.3 Clinical Applications 306
25.2.4 Associations Between Preoperative Assessments and Clinical Outcomes 
308 
25.3 Discussion 309
25.4 Conclusions 309
References 309
26 Magnetic Resonance Imaging 
311 
26.1 Introduction 311
26.2 Technique 311
26.2.1 MRI Coil 311
26.2.2 Preparation 312
26.2.3 Imaging Protocol 312
26.3 MRI Findings 312
26.4 Accuracy for Sphincter Defects 313
26.5 Accuracy for Sphincter Atrophy 315
26.6 MRI in the Management of Fecal-incontinent Patients 
316 
26.7 Conclusions 316
References 316
Invited Commentary 318
References 319
27 Anorectal Manometry 
320 
27.1 Introduction 320
27.2 Anorectal Manometry 321
27.3 Anorectal Manometry and Fecal Incontinence 
321 
27.4 Anorectal Manometry and Treatment of Fecal Incontinence 
322 
27.5 Conclusions 322
References 322
Invited Commentary 324
28 Sphincter Repair and Postanal Repair 
326 
28.1 Introduction 326
28.2 Workup 327
28.3 Indication 327
28.4 Technique 327
28.5 Special Technical Remarks 327
28.6 Special Problems 328
28.7 Short-term Results of Sphincteroplasty 
329 
28.8 Long-term Results of Sphincteroplasty 
329 
28.9 Quality of Life 330
28.9.1 Literature 330
28.9.2 Third-degree Sphincter Tears without Secondary Repair 
331 
28.10 Postanal Repair 331
28.11 Conclusions 332
References 332
29 Dynamic Graciloplasty 
336 
29.1 Introduction 336
29.2 Background 337
29.3 Preoperative Assessment 337
29.4 Indications 337
29.5 Technique 338
29.6 Results 339
References 339
30 Radiofrequency Energy and Injectable Biomaterials 
341 
30.1 Introduction 341
30.2 Radiofrequency Energy Delivery (Secca® Procedure) 
341 
30.2.1 Technique 342
30.2.2 Results 343
30.3 Injectable Biomaterials 343
30.3.1 Technique 343
30.3.2 Results 343
References 344
31 Artificial Bowel Sphincter 
345 
31.1 Introduction 345
31.2 Artificial Bowel Sphincter 346
31.3 Results 348
31.4 Discussion 350
31.5 Conclusions 351
References 351
32 Sacral Neuromodulation 
352 
32.1 Introduction 352
32.2 Technical Improvements 353
32.3 Mechanisms of Action 354
32.4 Indications 354
32.5 Prognostic Factors 354
32.6 Long-term Outcome and Quality of Life 
355 
32.7 Cost-effectiveness of Sacral Nerve Stimulation for Fecal Incontinence 
355 
References 355
33 Future Treatment 
357 
33.1 Introduction 357
33.2 Pathophysiological and Behavioral Aspect 
357 
33.3 Diagnostic Problems 358
33.3.1 Prevention of Incontinence 
358 
33.3.2 Diagnostic Tests and Normal Values 
358 
33.3.3 Standardization of Quality of Life 358
33.3.4 Study of Pathophysiological Mechanisms 
358 
33.4 Research Priorities 358
33.5 Development of Novel Imaging with Treatment Applications 
359 
33.6 Development of Novel Treatments 360
33.6.1 Physiopathology and Molecular Mechanisms of Incontinence 
360 
33.6.2 Potential Cell-based Strategies to Restore the Urinary or Anal Sphincter Function 
361 
33.7 Conclusions 361
References 361
Invited Commentary 363
References 364
34 Biofeedback 
366 
34.1 Introduction 366
34.2 Technique 366
34.3 Biofeedback in Fecal Incontinence: Evidence-based Medicine 
368 
References 369
35 Medical Treatment 
371 
35.1 Introduction 371
35.2 Hygienic Measures 371
35.3 Bowel Habits 371
35.4 Dietary Modification 372
35.5 Medical Treatment 372
References 372
Invited Commentary 374
References 375
Section VI Pelvic Organ Prolapse 
376 
Pelvic Organ Prolapse: Introduction 
378 
References 381
36 Imaging as a Key to Understanding the Causes of Pelvic Organ Prolapse 
383 
References 386
37 Endoluminal Ultrasonography 
387 
37.1 Introduction 387
37.2 Levator Ani Damage 388
37.3 Cystocele 390
37.4 Rectocele 392
37.5 Intussusception 393
37.6 Mucosal Rectal Prolapse 395
37.7 Enterocele 395
37.8 Pelvic Floor Dyssynergy 396
37.9 Uterovaginal Prolapse 397
37.10 Postoperative Follow-up 398
37.11 Discussion 398
37.12 Conclusions 399
References 400
38 Translabial Ultrasonography 
402 
38.1 Introduction 402
38.2 The Anterior Compartment 402
38.2.1 Residual Urine 404
38.2.2 Bladder Neck Mobility 404
38.2.3 Funneling and Stress Incontinence 405
38.2.4 Color Doppler Imaging of Stress Incontinence 
405 
38.2.5 Cystocele 406
38.2.6 Urethral and Paraurethral Pathology 
406 
38.2.7 Detrusor Wall Thickness 408
38.2.8 Other Bladder Pathology 409
38.3 The Central Compartment 409
38.3.1 Uterine Descent 409
38.3.2 Vault Prolapse 410
38.4 The Posterior Compartment 410
38.4.1 Rectocele 410
38.4.2 Enterocele 411
38.4.3 Rectal Intussusceptionand Prolapse 411
38.5 Postoperative Findings 413
38.5.1 Anterior Colporrhaphy/Vaginal Paravaginal Repair 
413 
38.5.2 Colposuspension 413
38.5.3 Fascial/Synthetic Traditional Slings 413
38.5.4 Injectables 414
38.5.5 Suburethral Slings 415
38.5.6 Mesh Implants in Prolapse Surgery 416
38.6 The Levator Hiatus and Muscle 417
38.7 Outlook 422
References 422
39 Cystography and Defecography 
426 
39.1 Introduction 426
39.2 Lower Urinary Tract Conditions 426
39.2.1 Imaging Technique 427
39.2.2 Image Analysis 427
39.3 Evacuation Conditions 429
39.4 Conclusions 430
References 431
40 Magnetic Resonance Imaging 
432 
40.1 Introduction 432
40.2 Pelvic Organ Prolapse versus Pelvic Floor Relaxation 
433 
40.3 Anterior Compartment Abnormalities 
434 
40.3.1 Cystocele 434
40.4 Middle Compartment Abnormalities 
434 
40.5 Posterior Compartment Abnormalities 
435 
40.5.1 Rectocele 435
40.5.2 Enterocele 436
40.5.3 Intussusception and Rectal Prolapse 
436 
40.5.4 Dyssynergic Defecation 437
References 438
Invited Commentary 440
Invited Commentary 442
41 Anorectal Manometry 
444 
References 445
Invited Commentary 447
42 Management of Pelvic Organ Prolapse: a Unitary or Multidisciplinary Approach? 
448 
42.1 Introduction 448
42.2 Why a Multidisciplinary Approach? 
448 
42.3 The Present and Future 449
42.4 The Need for a Common Language 450
42.5 Pelviperineology: an Evolving Discipline 
450 
42.6 The Need for a Holistic Vision 450
References 451
43 The Abdominal Approach to Urogenital Prolapse 
452 
43.1 Introduction 452
43.2 The Abdominal Approach 452
43.3 The Surgical Approach to the Vaginal Apex 
453 
43.4 Abdominal Sacrocolpopexy 455
43.5 Results Compared to the Vaginal Approach 
458 
43.6 Uterine Sparing 459
43.7 Conclusions 459
References 459
44 The Perineal Approach to Urogenital Prolapse 
462 
44.1 Introduction 462
44.2 Theoretical Background of Modern Reconstructive Urogynecological Surgery Based on Integral Theory 
463 
44.3 Prostheses in Urogynecology 463
44.4 The Surgical Perineal Approach 464
44.4.1 Urogenital Prolapse and Functional Abnormalities 
464 
44.4.2 Urinary Incontinence 465
44.4.3 Urogenital Prolapse 465
References 467
45 The Laparoscopic Approach to Pelvic Floor Surgery 
468 
45.1 Laparoscopy and Pelvic Floor Surgery 
468 
45.2 Stress Urinary Incontinence: Laparoscopic Colposuspension 
469 
45.2.1 Introduction 469
45.2.2 The Technique of Laparoscopic Colposuspension 
469 
45.2.2.1 Patient’s Preparation and Positioning 469
45.2.2.2 Preperitoneal or Transperitoneal Approach 469
45.2.2.3 Dissection of the Operative Field 469
45.2.2.4 Suture Suspension Technique, by either Staplers or Meshes 
470 
45.2.2.5 End of Operation and Postoperative Regimen 
470 
45.2.2.6 Complications 470
45.2.3 Results 470
45.2.4 Conclusions 471
45.3 Laparoscopy and Uterineand Vault Prolapse 
471 
45.3.1 Introduction 471
45.3.2 Technique of Laparoscopic Sacrocolpopexy 
471 
45.3.2.1 Patient's Preparation and Positioning 471
45.3.2.2 Retroperitoneal Dissection 472
45.3.2.3 Mesh and Suturing Technique 472
45.3.2.4 End of Operation and Postoperative Regimen 
473 
45.3.2.5 Complications 473
45.3.3 Results 474
45.3.4 Choice of the Mesh Material 475
45.3.5 The Learning Process and Robotic Surgery 
476 
45.3.6 Conclusions 477
References 477
46 Total Pelvic Floor Reconstruction 
480 
46.1 Introduction 480
46.2 Pathogenesis 481
46.3 Diagnosis 481
46.4 Total Pelvic Floor Reconstruction 481
46.5 Surgical Principles for Organ Prolapse Repair 
483 
46.6 Traditional Vaginal Repairs 483
46.6.1 Vaginal Excision and Suturing 483
46.6.2 The Manchester Repair 483
46.6.2.1 “Levator Approximation” 483
46.7 Abdominal or Laparoscopic Repairs for Cystocoele or Apical/Uterine Prolapse 
483 
46.8 Posterior Sling Suspensions: Infracoccygeal Sacropexy for Uterine/Vault Prolapse 
484 
46.9 Large Mesh Repairs 484
46.10 Direct Repair of the Suspensory Ligaments by the Tissue Fixation System: a New Direction for Total Pelvic Floor Repair 
484 
46.10.1 Prolapse Applications of the TFS Mini-sling System 
485 
46.10.2 Large Rectocele Repair 485
46.11 Conclusions 486
References 486
Invited Commentary 487
References 489
47 The Abdominal Approach to Rectal Prolapse 
490 
47.1 Introduction 490
47.2 Etiology 490
47.3 Assessment of Patients with Rectal Prolapse and Associated Symptoms 
491 
47.4 Selection of Patients for Abdominal Procedures 
492 
47.5 Abdominal Procedures 492
47.5.1 Ripstein Procedure (Anterior Sling Rectopexy) 
492 
47.5.2 Posterior Mesh Rectopexy 493
47.5.3 Suture Rectopexy 494
47.5.4 Sigmoid Resection Associated with Rectopexy 
494 
47.6 Abdominal Surgical Techniques 494
47.7 Minimally Invasive Approach 496
47.8 Incontinence Improvements and Mechanisms 
497 
47.9 Management of Recurrent Rectal Prolapse 
497 
47.10 Conclusions 498
References 498
48 The Perineal Approach to Rectal Prolapse 
502 
48.1 Introduction 502
48.2 Delorme’s Operation 503
48.3 Altemeier’s Operation 504
48.4 Other Operations 506
References 506
Invited Commentary 508
References 511
49 The Laparoscopic Approach to Rectal Prolapse 
513 
49.1 Introduction 514
49.2 Preoperative Evaluation 514
49.2.1 Risk Assessment 514
49.2.2 Workup 514
49.2.2.1 Defecography 514
49.2.2.2 Colorectal Transit Time 514
49.2.2.3 Colonoscopy 515
49.2.2.4 Anal Manometry 515
49.3 Treatment Options 515
49.3.1 Rectopexy versus Mobilization Only 
515 
49.3.2 Suture Rectopexy 515
49.3.3 Mesh Rectopexy 516
49.3.4 Sigmoid Resection 516
49.4 Surgical Technique 517
49.4.1 Preoperative Care 517
49.4.2 Laparoscopic Suture Rectopexy 517
49.4.3 Laparoscopic Sigmoid Resection Sparing the Superior Rectal Artery 
518 
49.4.4 Postoperative Care 518
49.5 Outcomes 518
49.6 Conclusions 519
References 519
Invited Commentary 520
Suggested Reading 520
50 Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse 
521 
50.1 Introduction 521
50.2 Methods 522
50.3 Results 522
50.4 Discussion 522
50.4.1 Conscious Contraction (Bracing or “Performing the Knack”) to Prevent and Treat POP 
523 
50.4.2 Strength Training 523
50.5 Should PFMT be an Adjunct to Prolapse Surgery? 
523 
50.6 Conclusions 526
References 526
51 Medical Treatment of Irritable Bowel Syndrome, Constipation, and Obstructed Defecation 
528 
51.1 Introduction 528
51.2 Medical Treatment of Irritable Bowel Syndrome 
528 
51.2.1 Traditional Therapies 529
51.2.2 New Agents – Serotonin Axis 529
51.2.3 New Agents – Adrenergic Modulators 
529 
51.2.4 New Agents – Future Research 530
51.2.5 The Use of Probiotics in the Treatment of IBS 
530 
51.3 Medical Treatment of Slow-transit Constipation 
530 
51.4 Medical Treatment of Obstructed Defecation 
531 
References 531
Invited Commentary 533
Section VII Pelvic Pain 
535 
Pelvic Pain: Introduction 
536 
References 536
52 Painful Bladder Syndrome 
537 
52.1 Introduction 537
52.2 Definition 538
52.3 Epidemiology 538
52.4 Etiology and Pathogenesis 539
52.4.1 Infection 539
52.4.2 Mastocytosis 539
52.4.3 Dysfunctional Bladder Epithelium 539
52.4.4 Neurogenic Inflammation 539
52.4.5 Reduced Vascularization 540
52.4.6 Pelvic Floor Dysfunction 540
52.4.7 Autoimmunity 540
52.5 Diagnosis 540
52.6 Treatment 541
52.6.1 Conservative Therapy 542
52.6.2 Medical Therapy 542
52.6.2.1 Protection of the Mucosal Surface 542
52.6.2.2 Intravesical Instillation or Bladder Wall Injection 
543 
52.6.2.3 Pain Modulation 543
52.6.2.4 Immunologic Modulation 544
52.6.2.5 Multimodal Medical Therapy 544
52.6.3 Procedural Intervention 544
52.7 Conclusions 544
References 545
53 Pelvic Pain Associated with a Gynecologic Etiology 
549 
53.1 Introduction 549
53.2 Etiology of Pelvic Pain 549
53.2.1 Acute Pelvic Pain 549
53.2.2 Chronic Pelvic Pain 551
53.2.2.1 Cyclic Chronic Pelvic Pain 551
53.2.2.2 Non-Cyclic Chronic Pelvic Pain 552
53.3 Initial Assessment 554
53.4 Evaluation of Pelvic Pain of Gynecologic Origin 
554 
53.4.1 History 554
53.4.2 Physical Exam 555
53.4.3 Office Testing 557
53.4.4 Imaging 557
53.4.5 Surgical Evaluation 557
53.5 Treatment of Chronic Pelvic Pain of Gynecologic Origin 
558 
53.5.1 Infections 558
53.5.2 Vulvar Pain 558
53.5.3 Surgical Treatments 559
53.5.3.1 Laparoscopic Approach 559
53.5.3.2 Hysterectomy 560
53.5.3.3 Uterine Leiomyomas 560
53.5.3.4 Ovarian Neoplasms 560
53.5.3.5 Conditions Caused From Previous Surgery 
560 
53.5.4 Psychological Treatments 561
53.5.5 Alternative Medicine Treatments 561
53.6 Summary 561
References 561
54 Pelvic Pain Associated with a Coloproctologic Etiology 
564 
54.1 Introduction 565
54.2 Inflammatory Bowel Disease 565
54.2.1 Visceral Pain and Mechanical Properties of IBS Patient’s Colon-rectal Wall 
566 
54.2.2 Conclusion 567
54.3 Inflammatory Diseases 567
54.4 “Functional” Anorectal and Pelvic Pain 
567 
54.5 Irritable Bowel Syndrome (IBS) 568
54.6 Tumors 569
54.7 Infectious Diseases 569
54.7.1 Gonorrhea, Chlamydia 570
54.7.2 Herpes Simplex Virus 571
54.7.3 Syphilis 571
54.7.4 Diagnosis and Treatment 571
54.8 Endometriosis 571
54.9 Common Proctological Diseases 572
54.10 Post-surgical Pain 573
54.11 Additional Notes on Treatments 573
54.12 Conclusions 574
References 574
55 Surface Electromyography and Myofascial Therapy in the Management of Pelvic Pain 
578 
55.1 Introduction 578
55.2 Sources of Pain 579
55.3 Mechanisms of Pain 579
55.4 Vulvodynia 581
55.4.1 SEMG Studies 581
55.4.2 Management of Vulvodynia 
582 
55.5 Bladder Pain Syndrome 583
55.5.1 SEMG studies 584
55.5.2 Management of Painful Bladder 
585 
55.6 Rectal Pain 586
55.6.1 SEMG Findings 586
55.6.2 Management of Rectal Pain 586
55.7 General Guidelines for SEMG Pelvic Floor Protocols 
587 
55.7.1 Functional Features of Muscles 587
55.7.2 Important Steps in SEMG Muscle Retraining 
588 
55.7.3 Relaxation and Deactivation Training (Down-training) 
588 
55.8 Conclusions 590
References 590
56 Chronic Pelvic Pain: A Different Perspective 
593 
56.1 Introduction 593
56.2 Types of Chronic Pelvic Pain 593
56.3 Types of Unexplained Pelvic Pain 594
56.4 Incidence 594
56.5 Low Abdominal “Dragging” Pain and Collision Dyspareunia 
594 
56.5.1 Perspective 594
56.5.2 Characteristics 594
56.5.3 Relation to Periods 594
56.5.4 Pathogenesis 594
56.5.5 Diagnosis 594
56.5.6 Examination 595
56.5.7 Management 596
56.5.7.1 Non-surgical Management 596
56.5.7.2 Surgery 596
56.5.7.2.1 Posterior Tissue Fixation System Sling 596
56.6 Vulvodynia (“Vulvar Vestibulitis”) 597
56.6.1 Definition 597
56.6.2 Experiment 1 597
56.6.3 Experiment 2 597
56.7 Conclusions 597
References 597
Invited Commentary 598
Suggested Reading 599
Invited Commentary 600
Section VIII Fistula 
602 
Fistula: Introduction 
603 
Epidemiology 603
Diagnosis 604
Fistula Classifications 604
Vesicovaginal Fistulae 605
Rectovaginal Fistulae 605
Treatment 605
References 607
57 Urogenital Fistulae 
609 
57.1 Introduction 609
57.2 Vesicovaginal Fistulae 609
57.3 Urethrovaginal Fistulae 610
57.4 Vesicovaginal Fistula Repair 610
57.4.1 Flap Techniques 611
57.4.1.1 Martius Flap Technique 612
57.4.1.2 Latzko Colpocleisis 613
57.5 Principles of Urethrovaginal Fistula Repair 
614 
References 614
58 Rectovaginal Fistulae 
616 
58.1 Definition 616
58.2 Etiology 616
58.3 Classification 618
58.4 Presentation 618
58.5 Assessment and Investigations 618
58.6 Treatment 619
58.6.1 Surgical Techniques 620
58.6.1.1 Endorectal Advancement Flap 620
58.6.1.2 Transvaginal Flap 621
58.6.1.3 Excision of Fistula and Layered Closure 623
58.6.1.4 Rectal Sleeve Advancement Flap 623
58.6.1.5 Episio/perineoproctotomy 624
58.6.1.6 Tissue Interposition 624
58.6.1.7 Use of Biomaterials 625
58.6.1.8 Abdominal Operations 626
58.6.1.9 Other Techniques 627
58.6.2 Choice of Surgery 627
58.6.2.1 Peripartum Rectovaginal Fistula 627
58.6.2.2 Crohn’s Disease 628
58.6.2.3 RVF Due to Radiation 630
58.6.2.4 RVF Due to Malignancy 630
58.6.2.5 Postoperative (Iatrogenic) RVF 630
58.6.2.6 Recurrent RVF 632
58.6.3 Suggested Algorithm 632
58.7 Conclusions 632
References 632
59 Anorectal Fistulae 
636 
59.1 Introduction 636
59.2 Assessement of Anorectal Fistulae 638
59.2.1 Physical Examination 638
59.2.2 Fistulography 639
59.2.3 Endoanal Ultrasonography 640
59.2.4 Magnetic Resonance Imaging 646
59.3 Surgical Treatment of Anorectal Fistulae 
648 
59.3.1 Drainage 648
59.3.2 Fistulotomy/Fistulectomy 649
59.3.3 Fistulotomy in Acute Anorectal Sepsis 
650 
59.3.4 Setons 650
59.3.5 Advancement Flaps 651
59.3.6 Fibrin Sealant 652
59.3.7 Anal Plug 653
59.3.8 Other Treatments 655
References 655
Invited Commentary 658
Invited Commentary 659
Urogenital Fistulae 659
Rectovaginal Fistulae 660
Perianal Fistulae 662
References 664
Section IX Failure or Recurrence after Surgical Treatment: What to Do When it All Goes Wrong 
665 
Failure or Recurrence after Surgical Treatment: Introduction 
666 
Proper Patient Selection 667
What to Do with Unexpected Postoperative Complications 
667 
Complications of Midurethral Sling Surgery 667
Mesh Extrusions and Exposure 668
How to Manage Postoperative Tapeor Mesh Extrusions 669
How to Prevent and Manage Dyspareunia and/or Vaginal Pain after Graft Surgery 
669 
How to See What Went Wrong and Why 670
Conclusions 671
References 672
60 Imaging and Management of Complications of Urogynecologic Surgery 
674 
60.1 Introduction 674
60.2 Intra-operative Complications Involving Anti-incontinence Procedures 
674 
60.2.1 Overview 674
60.2.2 Slings 675
60.2.3 Retropubic Procedures 677
60.3 Complications of Pelvic Organ Prolapse Surgery 
681 
60.3.1 Overview 681
60.3.2 Apical Segment Complications 681
60.3.3 Lateral Vaginal Complications 683
60.3.4 Anterior Compartment Complications 
683 
60.3.5 Posterior Compartment Complications 
684 
60.3.6 Introital Vaginal Complications 686
60.4 Summary 688
References 688
Invited Commentary 690
References 691
61 Investigation and Management of Complications after Coloproctological Surgery 
692 
61.1 Introduction 692
61.2 Infection-related Complications 692
61.2.1 Anastomotic Leak 692
61.2.2 Abscesses 694
61.2.2.1 Small Perianastomotic Abscess (< 3 cm)
61.2.2.2 Larger Perianastomotic Abscess (> 3 cm)
694 
61.2.2.3 Abscess in Continuity with Leak 695
61.2.3 Low Rectal Anastomotic Sinus 695
61.2.4 Anastomotic Stricture 696
61.2.4.1 Colonic 696
61.2.4.2 Rectal 696
61.2.5 Fistula 697
61.2.6 Wound Infection 697
61.3 Intraoperative Organ Injury 697
61.3.1 Ureteric Injury 697
61.3.2 Splenic Injury 697
61.4 Stomal Complications 698
61.4.1 Stoma Retraction 698
61.4.2 Peristomal Skin Complications 698
61.5 Thromboembolic Complications 698
61.6 Sexual Dysfunction 698
61.6.1 Sympathetic Damage 699
61.6.2 Parasympathetic Damage 699
61.6.3 Treatment of Postoperative Sexual Dysfunction 
700 
61.7 Fecal Incontinence 700
61.8 Complications after Surgery for Functional Disorders 
700 
61.8.1 Fecal Incontinence 700
61.8.2 Rectal Prolapse 701
61.8.3 Obstructed Defecation 701
References 702
Invited Commentary 703
Anastomotic Complications 703
Stomal Problems 703
Splenic and Ureteric Injuries 704
Thromboembolic Complications 704
Functional Complications 704
Invited Commentary 705
Incontinence 705
Recurrence of the Disease 705
Stenosis of the Anal Canal 706
Deformation of the Anal Canal 707
References 707
Subject Index 708